Atilla Sezgin

Diaphragmatic paralysis after cardiac surgery in children: incidence, prognosis and surgical management.

Diaphragmatic paralysis (DP) after cardiac surgery is an important complication especially in infants. We analyzed the incidence, clinical course, surgical management and follow up of the patients with DP, retrospectively. Between 1996 and 2005, 3,071 patients underwent cardiac surgery. Total number of patients with DP was 152 (4.9%). Out of 152 patients, 42 were surgically treated with transthoracic diaphragm plication (1.3%). The overall incidence of diaphragm paralysis was higher in correction of tetralogy of Fallot (31.5%), Blaloc–Taussig (B–T) shunt (11.1%) and VSD closure with pulmonary artery patch plasty (11.1). The incidence of DP which require plication was higher in B–T shunt (23.8%) arterial switch (19%) and correction of tetralogy of Fallot (11.9%). Mean and median age at the time of surgery were 17.8±3.6 and 6 months, respectively. Median time from cardiac surgery to surgical plication was 12 days. Indications for plication were repeated reintubations (n=22), failure to wean from ventilator (n=12), recurrent lung infections (n=5) and persistent respiratory distress (n=3). Mortality rate was 19.1%. Being under 1 year of age, pneumonia and plication 10 days after mechanical ventilation were associated with higher incidence mortality (P<0.05). Phrenic nerve injury is a serious complication of cardiac surgery. It is more common after some special procedures. Spontaneous recovery is very rare. Being under 1 year of age, plication after 10 days from the surgery and pneumonia are major risk factors for mortality even in plicated patients. Transthoracic plication is helpful if performed early.

RIFLE Criteria for Acute Kidney Dysfunction Following Heart Transplantation: Incidence and Risk Factors

RIFLE criteria have been used to determine the incidence of acute kidney dysfunction (AKD) after orthotopic liver transplantation (OLT). However, no studies have focused on the incidence of AKD after OLT in patients with normal pre-OLT kidney functions. Using the RIFLE criteria, we determined the incidence and risk factors for AKD after OLT in patients with normal pre-OLT kidney function. We retrospectively analyzed the records of 112 patients who underwent OLT from January 2000 to February 2009 with normal prior kidney function. We investigated three levels of renal dysfunction outlined in the RIFLE criteria: risk (R); injury (I); and failure (F). Preoperative, intraoperative, and postoperative variables were collected. AKD occurred in 64 (57%) OLTs with risk, injury, and failure frequencies of 19%, 11%, and 28%, respectively. Compared with those who did not develop AKD postoperatively, those who did had significantly higher MELD scores (19 ± 7 vs 16 ± 8; P = .018), more frequently use of inotropic agents intraoperatively (54% vs 35%; P = .070), more colloid treatment (300 ± 433 mL vs 105 ± 203 mL; P = .007), longer anhepatic phase (88.0 ± 42.0 minutes vs 73.0 ± 20.0 minutes; P = .037), and a greater incidence of intraoperative acidosis (64% vs 44%; P = .047). Logistic regression analysis revealed that MELD score (odds ratio 1.107, 95% CI 1.022-1.200, P = .013), duration of anhepatic phase (odds ratio 1.020 95% CI 1.000-1.040, P = .053), and intraoperative acidosis (odds ratio 0.277 95% CI 0.093-0.825 P = .021) were independent risk factors for AKD. In conclusion, our results suggested that, based on RIFLE criteria, AKD occurs in more than half of OLTs postoperatively. A higher MELD score, longer anhepatic phase, and occurrence of intraoperative acidosis were associated with AKD.

Efficacy of allopurinol pretreatment for prevention of contrast-induced nephropathy: a randomized controlled trial

BACKGROUND Contrast-induced nephropathy (CIN) remains a common complication of radiographic procedures. Radiocontrast agents can cause a reduction in renal function that may be due to reactive oxygen species. Conflicting evidence suggests that administration of antioxidants prevents CIN. METHODS We assessed the efficacy of allopurinol in preventing CIN. We prospectively randomized 159 patients with a serum creatinine concentration >1.1mg/dL undergoing cardiac catheterization/interventions to receive allopurinol (300 mg, p.o.) 24h before administration of radiocontrast agent and hydration (1mg/kg/hN/saline for 12h pre- and post-contrast, n=79), or hydration alone (1mg/kg/hN/saline for 12h pre- and post-contrast, n=80). RESULTS CIN occurred in 6 of 80 patients (7.5%) in the control group and no subjects in the allopurinol group (p=0.013). In the allopurinol group, median serum creatinine concentration decreased significantly from 1.43 mg/dL [1.1-4.15 mg/dL] to 1.35 mg/dL [0.7-4.15 mg/dl] at 48 h and to 1.27 mg/dL [0.66-4.37 mg/dL] at 4 days after radiocontrast administration (p<0.0001 and p<0.0001 compared with baseline, respectively). In the control group, median serum creatinine concentration decreased non-significantly from 1.48 mg/dL [1.1-2.96 mg/dL] to 1.43 mg/dL [0.73-3.02 mg/dL] and to 1.45 mg/dL [0.86-3.71 mg/dL] (p=0.045 and p=0.57, respectively) 48 h and 4 days after radiocontrast administration. CONCLUSIONS Prophylactic oral administration of allopurinol, along with hydration, may protect against CIN in high-risk patients undergoing coronary procedures.

Giant left atrial appendage aneurysm: the third ventricle!

The giant congenital intrapericardial aneurysmal dilatation of the left atrial appendage without mitral valve disease is a very rare condition that is generally diagnosed in older patients. The problem is usually accompanied with supraventricular rhythm disorders and life-threatening systemic thromboembolism. Complete surgical correction is possible, and it should be performed immediately after the diagnosis. We are going to describe a patient with a history of cerebral thromboembolism and palpitation who was diagnosed with congenital intrapericardial aneurysmal dilatation of the left atrial appendage. The condition was identified by means of echocardiography and was surgically treated by resection of the appendage containing the aneurysm.

Follow-Up of Heart Transplant Recipients with Serial Echocardiographic Coronary Flow Reserve and Dobutamine Stress Echocardiography to Detect Cardiac Allograft Vasculopathy

BACKGROUND Implementation of reliable noninvasive testing for screening cardiac allograft vasculopathy (CAV) is of critical importance. The most widely used modality, dobutamine stress echocardiography (DSE), has moderate sensitivity and specificity. The aim of this study was to assess the potential role of serial coronary flow reserve (CFR) assessment together with DSE for predicting CAV. METHODS A total of 90 studies were performed prospectively over 5 years in 23 consecutive heart transplant recipients who survived >1 year after transplantation. Assessment of CFR with transthoracic Doppler echocardiography, DSE, coronary angiography, and endomyocardial biopsy was performed annually. Results of CFR assessment and DSE were compared with angiographic findings of CAV. RESULTS Acute cellular rejections were excluded by endomyocardial biopsies. CAV was detected in 17 of 90 angiograms. Mean CFR was similarly lower in both mild (CAV grade 1) and more severe (CAV grades 2 and 3) vasculopathy, but wall motion score index became higher in parallel with increasing grades of vasculopathy. Any CAV by angiography was detected either simultaneously with or later than CFR impairment, yielding 100% sensitivity for CFR. The combination of CFR and DSE increased the specificity of the latter from 64.3% to 87.2% without compromising sensitivity (77.8%). CONCLUSIONS CFR is very sensitive for detecting CAV and increases the diagnostic accuracy of DSE, raising the potential for patient management tailored to risk modification and to avoid unnecessary angiographic procedures.

Mitral Valve Replacements in Redo Patients with Previous Mitral Valve Procedures: Mid‐Term Results and Risk Factors for Survival

Abstract  Objective: We aimed to investigate the risk factors for hospital mortality, short (five years) and mid‐term (10 years) survival in patients who underwent mitral valve replacements in redo patients with previous mitral valve procedures. Patients and Methods: Between September 1989 and December 2003, 62 redo patients have undergone mitral valve replacements due to subsequent mitral valve problems. Preoperative, operative, and postoperative data were analyzed retrospectively and evaluated for risk factors affecting hospital mortality, mid‐ and long‐term survival. Results: The hospital mortality was 6.4%. The one‐, five‐, and 10‐year actuarial survival rates were 94%± 2%, 89%± 6%, and 81 ± 9%. New York Heart Association (NYHA) functional class IV, low left ventricular ejection fraction (<35%), increased left ventricular end‐diastolic diameter (LVEDD) > 50 mm, female gender, pulmonary edema, and urgent operations were found to be risk factors in short‐term survival. NYHA functional class IV, low left ventricular ejection fraction, increased LVEDD, and increased left atrial diameter (LA > 60 mm) were risk factors in mid‐term survival. Conclusion: Redo mitral valve surgery with mechanical prosthesis offers encouraging short‐ and mid‐term survival. NYHA functional class IV, low left ventricular ejection fraction, and increased left ventricular diameters were especially associated with increased short‐ and mid‐term mortality. Earlier surgical management before the development of severe heart failure and myocardial dysfunction would improve the results of redo mitral valve surgery.

Assessing exercise performance after heart transplantation

Abstract:  Objective:  Heart transplantation improves the survival rate and quality of life in patients with severe symptoms of congestive heart failure and an ejection fraction of 20% or less. Despite marked symptomatic and clinical improvement in those who undergo heart transplantation, exercise capacity often remains reduced, and the factors limiting exercise performance during the post‐transplantation period remain unclear. This study was performed to investigate the factors affecting exercise capacity in heart transplantation recipients.

Familial dilated cardiomyopathy hypergonadotrophic hypogonadism associated with thyroid hemiagenesis

Fewer than 10 families have been reported with dilated cardiomyopathy and hypergonadotrophic hypogonadism (DCM-HH), which has been described as the ‘‘congestive cardiomyopathy-hypertrophic hypogonadism syndrome,’’ and may include mental retardation, broad nasal base, collagenoma, blepharoptosis, arachnodactyly, kyphoscoliosis,deafness, blindness, and minor bone abnormalities [Najjar et al., 1973, 1984; Sacks et al., 1980; Malouf et al., 1985; Warren et al., 1987; Narahara et al., 1992]. Because the phenotype is variable, genetic heterogeneity is likely. We report a new family with three siblings, in whom the proband also had thyroid hemiagenesis. The propositus is a 19-year-old male of Turkish ancestry with DCM-HH born to unrelated parents. Two older sisters had DCM confirmed by echocardiography, one of whom died as a result of DCM at 13 years of age. An autopsy was not permitted by family. An affected living sister is currently under consideration for cardiac transplantation. She also has hypertrophic hypogonadism with a normal thyroid by ultrasonography and no additional features of DCM-HH. The patient’s parents and youngest (third) sister were clinically and echocardiographically normal. At age 14 years, the propositus had been admitted to hospital for evaluation of heart failure due to DCM diagnosed in early childhood, complicated by ventricular tachycardia and recurrent cardiac decompensation. Orthotopic heart transplantation was performed 12 months after initial admission, and he did well after the operation. At age 18 years, he had an endocrine consultation to evaluate delayed secondary sexual characteristics which included a eunuchoid appearance, absent facial hair and scant axillary and pubic hair, microphallus (stretched penile length 4 cm), and prepubertal testicular size (1 ml using Prader orchidometer). There were no palpable masses in either testicle. The right lobe of the thyroid gland was easily palpable, but the left lobe was nonpalpable. Hormonal assessment supported the diagnosis of hypergonadotrophic hypogonadism with serum total testosterone 220 ng/dl (normal range, 280– 880 ng/dl), serum-free testosterone 7.35 ng/ml (normal range, 10–42 ng/ml), luteinizing hormone 22.8 mIU/ml (normal range, 1.7–8.6 mIU/ml), and follicle-stimulating hormone 49.7 mIU/ml (normal range, 0.7–11.4 mIU/ml). He was treated with intramuscular testosterone at a dose of 250 mg every 3 weeks. After 3 months, the serum level of folliclestimulating hormone normalized (7.6 mIU/ml) and the serum-free testosterone level was 22.6 ng/ml. In the following months, the patient showed progressive muscular development, voice deepening, facial and body hair, penis growth to 8 cm, and increased testicular volume. Thyroid function tests at initial endocrine consultation were consistent with subclinical hypothyroidism. Thyroid ultrasonography and scintigraphy (sodium 99m Tc pertechnetate) showed absence of the left lobe of the thyroid gland and isthmus. Twenty-five to thirty percent of the cases of DCM are familial which can be transmitted as autosomal dominant, autosomal recessive, X-linked, or as a matrilineal (mitochondrial) trait [Seidman and Seidman, 2001]. Table I summarizes the clinical data on the ‘‘syndrome’’ of DCM combined with hypergonadotrophic hypogonadism (DCM-HH) and other

[Serum gamma-glutamyltransferase activity: a new marker for coronary artery bypass graft disease].

OBJECTIVES Serum gamma-glutamyltransferase (GGT) activity has been shown to be related to the development of atherosclerosis and cardiovascular events. We evaluated the association between GGT and severe graft disease in patients undergoing coronary artery bypass graft (CABG) surgery. STUDY DESIGN We evaluated 113 patients (mean age 62±9 years; range 21 to 81 years) who underwent control coronary angiography after a mean of 39 months (range 18 to 84 months) following CABG surgery. A graft was considered patent if there was <70% stenosis or severely diseased if there was ≥70% stenosis on coronary angiography. Preoperative serum GGT levels were measured in all the patients and none had severe systemic or hepatobiliary disease. The association between serum GGT level and severe graft disease was investigated. The grafts were also evaluated separately. RESULTS Coronary angiography showed severe graft disease involving at least one graft in 65 patients (57.5%). Serum GGT level was significantly higher in patients with severe graft disease (p=0.001). ROC curve analysis yielded a cut-off value of 29.5 U/l for serum GGT level to predict severe graft disease (area under the curve: 0.69) with 48% sensitivity and 82% specificity. While GGT levels were similar for internal mammary artery grafts (p>0.05), radial artery grafts and saphenous vein grafts (SVG) with severe graft disease were associated with significantly higher GGT levels (p=0.003 and p<0.001, respectively). In multivariate analysis, family history of coronary artery disease at a young age (OR 2.46, 95% CI 1.08-5.61, p=0.03) and serum GGT (OR 1.03, 95% CI 1.00-1.07, p=0.05) were independent predictors of severe graft disease. Separate analysis based on the graft types showed that GGT was an independent predictor of severe graft disease for only SVG (OR 1.02, 95% CI 1.00-1.04, p=0.03). CONCLUSION Serum GGT level may be an independent marker for the development of severe SVG disease in patients undergoing CABG surgery.

Apoptosis and proliferation of cardiomyocytes and interstitial mononuclear cells: association with rejection and macrophage infiltration.

Previous studies have noted that acute rejection episodes (AREs) may lead to loss of cardiomyocytes in transplanted hearts. The aim of this study was twofold; first, to assess the degree of apoptotic cells and to compute the proliferation index of cardiomyocytes and mononuclear interstitial infiltrates in cardiac allografts. Second, we sought to determine whether apoptosis involved in AREs was associated with macrophage infiltration. Among 28 endomyocardial biopsies, 18 showed AREs and the remaining 10 biopsies, nonspecific changes, the control group. All biopsies were immunostained with Ki-67 and CD68 antibodies. Apoptotic cells were counted using the terminal deoxyncleotidyl transferase dUTP nick end labeling method. Apoptotic death of cardiac myocytes and interstitial mononuclear cells was significantly greater in cases of allograft rejection compared with the control group (P < .05). In addition, compared to the control group, ARE cases showed a greater proliferation index of cardiac myocytes and interstitial cells (P < .05). Macrophage infiltration was significantly greater in ARE cases and macrophage infiltration showed a linear association with both apoptosis and proliferation of myocytes and interstitial cells (P < .001). In conclusion, we verified the presence of apoptotic cell death during acute rejection in heart transplants. Apoptotic cell death was significant among interstitial cells but it was less among cardiac myocytes. Macrophage infiltration had a great influence on apoptotic cell death of myocytes and interstitial cells.