Bilgehan Savas Oz

Gastrointestinal complications after cardiac surgery

OBJECTIVE Gastrointestinal (GI) complications after cardiac surgery with cardiopulmonary bypass (CPB) are uncommon complications with significant morbidity and mortality rates. METHODS From 1988 to 1995, 36 GI complications were identified in 3158 patients who underwent cardiac surgery (1.14% incidence). The mortality rate was 13.9%. Complications included hemorrhage in the GI tract in 22, perforated ulcer in 3, acute cholecystitis in 3, pancreatitis in 2, mesenteric ischemia in 3, diverticulitis in 1 and liver failure in 2 patients. RESULTS Clinical risk factors included advanced age, combined coronary artery bypass grafting (CABG)-valve operation, postoperative low cardiac output (LCO), prolonged ventilation time, re-exploration of the chest, sternal infection and a positive history of peptic ulcer. Patients with a prolonged pump time had an increased risk of GI complications (P < 0.001). CONCLUSIONS Gastrointestinal complications, although of low incidence, carry a significantly high mortality, and the clinician must be alert to institute early appropriate treatment.

Surgical approach to ascending aorta in bicuspid aortic valve.

Abstract Objective: Former studies have pointed out that hemodynamic stress imposed by associated valvular disease is the primary factor in the development of ascending aorta dilatation. At present, intrinsic wall pathology is blamed for dilatation and aneurysm formation in bicuspid aortic valve (BAV). Materials and Methods: Aortic valve replacement (AVR) was performed on 78 adult patients with BAV. Patients were divided into two groups. Group I(n = 27)underwent only AVR. Group II(n = 51)underwent AVR and additional ascending aorta procedures such as Shawl‐Lapel aortoplasty(n = 12)and tailoring aortoplasty(n = 9). Dacron wrapping was performed after both techniques were done. Ascending aorta replacement was done on 11 patients by using composite graft. Supracoronary graft replacement was performed in 3 patients after AVR. Results: Ascending aorta diameter increment was 1.25 mm/year in normotensive and 2.80 mm/ year in hypertensive patients. Ascending aorta aneurysm (diameter > 55 mm) developed in eight patients in the postoperative period in group I. Ascending aorta dilatation did not develop in group II patients. Mean survival time ± standard error (SE) was 128 ± 11 and 99 ± 4 months and survival possibility was 77.78% and 92.16%. Freedom from reoperation was 65.4% and 95.9% in 8 years in group I and group II, respectively. Conclusion: Aortic wrapping with or without aortoplasty has a beneficial effect not only in dilated ascending aorta but also in all nondilated BAV patients with normal‐sized aortic diameter. Ascending aorta wrapping in BAV patients preserves the endothelial lining and prevents further dilatation, aneurysm formation, and dissection.(J Card Surg 2003;18:173‐180)

Preservation of Pleural Integrity during Coronary Artery Bypass Surgery Affects Respiratory Functions and Postoperative Pain: A Prospective Study

OBJECTIVE To evaluate the role of preserved pleural integrity in postoperative pain and respiratory functional status in patients undergoing coronary revascularization. METHODS Two hundred forty patients undergoing on-pump coronary artery bypass grafting between March 2004 and February 2005 were included in the present study. The patients were prospectively randomized and divided into either an opened pleura (OP) group (n=120, patients with an OP) or a closed pleura (CP) group (n=120, patients whose pleural integrity was preserved). Preoperative patient characteristics were similar. Postoperative respiratory functions were compared between the groups by chest x-rays, respiratory functional tests and arterial blood gas analyses. Postoperative pain was compared by using a multidimensional pain score. All the tests were examined by the same blinded clinician. RESULTS The mean age of the patients was 60.4+/-8.8 years. Postoperative bleeding and the duration of hospital stay were markedly higher in the OP group than in the CP group. The incidences of atelectasis and pleural effusion were also significantly higher in the OP group (P<0.01). Respiratory functions and postoperative pain scores were better in the CP group (P<0.01 and P=0.008, respectively). CONCLUSIONS Preserving pleural integrity has beneficial effects on the respiratory functions and postoperative pain after coronary revascularization. The preservation of pleural integrity results in better respiratory function, decreased hospital stay and cost, and as a consequence, a better surgical outcome.

Warfarin-induced skin necrosis after open heart surgery due to protein S and C deficiency.

Warfarin-induced skin necrosis is the rare but potentially devastating complication of anticoagulant therapy and commonly occurs in previously undetected C- and S-protein deficient patients. Because routine preoperative examination does not include protein C and S level measurement, detection of these patients preoperatively is generally not possible, which increases the risk of occurrence of this important complication. In this report we present and discuss such a patient, who died from warfarin-induced skin necrosis after coronary artery bypass surgery.

Supraclavicular control of patent internal thoracic artery graft flow during aortic valve replacement

BACKGROUND The mortality and morbidity of aortic valve replacement (AVR) after prior coronary artery bypass surgery (CABG) with patent left internal thoracic artery (LITA) is significant. The risk of LITA injury and inadequate myocardial preservation during the cross-clamp period may cause myocardial pump failure. METHODS A total of 43 patients with a patent LITA graft underwent AVR. The patients were divided into the two groups. Group 1 included 19 patients who underwent AVR with deep hypothermia (20 degrees C) without LITA clamping. Group 2 included 24 patients in whom LITA flow was controlled through supraclavicular occlusion and AVR performed with moderate hypothermia (28 degrees C). RESULTS Average cardiopulmonary bypass time (CPB) time was 118.79 +/- 20.36 minutes in group 1 and 102.67 +/- 9.66 minutes in group 2 (p = 0.006). Average cross-clamp time was 53.79 +/- 7.26 minutes in group 1 and 49.63 +/- 6.7 minutes in group 2 (p = 0.022). Inotropic support was required in 12 patients in group 1 and 4 patients in group 2 (p = 0.002). Average intensive care unit stay was 4.68 +/- 2.24 days in group 1 and 2.29 +/- 0.46 days in group 2 (p < 0.001). Average hospital stay was 11.84 +/- 2.91 days in group 1 and 8.04 +/- 2.38 days in group 2 (p < 0.001). Mortality due to myocardial failure developed in 4 patients in group 1 but in none of the patients in group 2 (p = 0.02). CONCLUSIONS Proximal control of LITA flow by extrathoracic supraclavicular occlusion reduces the incidence of myocardial failure due to nonhomogenous cardioplegia delivery to the anterior wall of the heart, resulting in improved myocardial protection and the elimination of the need for deep hypothermia.

True aneurysm formation in axillofemoral bypass with a reinforced ePTFE graft-a case report.

Since improvement in reinforced expanded polytetrafluoroethylene (ePTFE) grafts, true aneurysm and pseudoaneurysm formation have become relatively rare complications after axillofemoral reconstruction. This is a case report of a true aneurysm of an axillofemoral graft. The true aneurysm occurred 29 months after insertion of a reinforced ePTFE graft for aortoiliac occlusive disease. A mid-graft true aneurysm was identified during examinations without any trauma history. Continuous long-term follow-up is recommended for these reinforced ePTFE grafts because of rare aneurysm formation, preferably using duplex ultrasonography.

Anticoagulation After Coronary Artery Surgery in Patients With Polycythemia Vera: Report of Two Cases

Abstract  Polycythemia vera is a myeloproliferative disorder associated with the thromboembolic events. Normalization of the hematocrit and elevated platelet counts is obligatory to reduce the thrombotic risk of patients with PV. Therapeutic strategies include phlebotomy, myelosuppressive agents, and, more recently, interferon‐α. In addition, appropriate antiplatelet therapy should be administered to prevent life‐threatening complications and reducing the viscosity of the blood. Although aspirin is widely preferred in such patients, this monodrug therapy or combined with clopidogrel as an alternative approach might not be enough, especially after coronary artery surgery. Therefore, warfarin should be added to anticoagulant therapy. This short report describes the use of warfarin, associated with aspirin and clopidogrel as an anticoagulant regimen after coronary artery bypass surgery in two cases with polycythemia vera. We believe that a combination of warfarin with other oral antiplatelet agents may be more effective in preventing the coronary artery bypass graft thrombosis.

Pre-treatment before coronary artery bypass surgery improves post-operative outcomes in moderate chronic obstructive pulmonary disease patients.

Introduction Chronic obstructive pulmonary disease (COPD) has traditionally been recognised as a predictor of poorer early outcomes in patients undergoing coronary artery bypass grafting (CABG). The aim of this study was to analyse the impact of different COPD stages, as defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) spirometric criteria, on the early surgical outcomes in patients undergoing primary isolated non-emergency CABG Methods Between January 2008 and April 2012, 1 737 consecutive patients underwent isolated CABG in the Department of Cardiovascular Surgery of Gulhane Military Academy of Medicine; 127 patients with the diagnosis of moderate-risk COPD were operated on. Only 104 patients with available pulmonary function tests and no missing data were included in the study. Two different treatment protocols had been used before and after 2010. Before 2010, no treatment was applied to patients with moderate COPD before the CABG procedure. After 2010, a pre-treatment protocol was initiated. Patients who had undergone surgery between 2008 and 2010 were placed in group 1 (no pre-treatment, n = 51) and patients who had undergone surgery between 2010 and 2012 comprised group 2 (pre-treatment group, n = 53). These two groups were compared according to the postoperative morbidity and mortality rates retrospectively, from medical reports. Results The mean ages of the patients in both groups were 62.1 ± 7.6 and 64.5 ± 6.4 years, respectively. Thirty-nine of the patients in group 1 and 38 in group 2 were male. There were similar numbers of risk factors such as diabetes, hypertension, renal disease (two patients in each group), previous stroke and myocardial infarction in both groups. The mean ejection fractions of the patients were 53.3 ± 11.5% and 50.2 ± 10.8%, respectively. Mean EuroSCOREs of the patients were 5.5 ± 2.3 and 5.9 ± 2.5, respectively in the groups. The average numbers of the grafts were 3.1 ± 1.0 and 2.9 ± 0.9. Mean extubation times were 8.52 ± 1.3 hours in group 1 and 6.34 ± 1.0 hours in group 2. The numbers of patients who needed pharmacological inotropic support were 12 in group 1 and five in group 2. Duration of hospital stay of the patients was shorter in group 2. While there were 14 patients with post-operative atrial fibrillation (PAF) in group 1, the number of patients with PAF in group 2 was five. Whereas there were seven patients who had pleural effusions requiring drainage in group 1, there were only two in group 2. There were three mortalities in group 1, and one in group 2. There were no sternal infections and sternal dehiscences in either group. Conclusion Pre-treatment in moderate-risk COPD patients improved post-operative outcomes while decreasing adverse events and complications. Therefore for patients undergoing elective CABG, we recommend the use of medical treatment.

Risk factors for short- and long-term survival in patients undergoing re-replacement due to prosthetic valve dysfunction

The purpose of this study was to investigate the effect of preoperative, intraoperative, and postoperative variables on early, mid-, and long-term outcome of re-replacement of prosthetic valves. Between February 1989 and January 2004, 192 patients who were treated for prosthetic valve dysfunction were analyzed retrospectively using a computer-based databank system. Prosthetic valve re-replacements were performed, including 164 cases of second, 10 cases of third, and 2 cases of fourth valve re-replacement. The number of re-replacements amounted to 6.1% (n = 176) of total valvular surgery. There were 90 male patients (46.8%) and the mean age was 61.6 ± 8.3 years. Median follow-up time was 7.8 years. Hospital mortality was 11.7% (n = 14). Low ejection fraction (EF), advanced New York Heart Association (NYHA) functional class, prosthetic valve endocarditis, and pulmonary edema were found to be predictors of early mortality. The 1-, 5-, and 10-year actuarial survival rates were 92% ± 3%, 78% ± 3%, and 45% ± 2%, respectively. Multivariate analysis revealed that NYHA class IV, low EF, prosthetic valve endocarditis, advanced age, left ventricular end-systolic diameter (LVESD) >50 mm, and double valve re-replacement were independent predictors of late mortality. In our study NYHA class IV, low EF, prosthetic valve endocarditis, and LVESD >50 mm were found to be risk factors for both hospital mortality and long-term survival. In addition, pulmonary edema, advanced age, and double valve replacement were also risk factors over the long term. Aggressive treatment of endocarditis and early re-replacement before aggravation of left ventricle function will improve the results.

Surgical repair of aneurysm of arteriovenous fistula in patients with chronic renal failure.

The aim of the study The aim of the study was to show the efficacy and results of aneurysm reconstruction that was developed for relieving the patients from pain and mass effects and to give an early hemodialysis option. Material and methods Medical records were retrospectively screened over a period of 17 years to identify patients diagnosed with and surgically treated for aneurysm of an AV fistula. Twenty-eight patients were included in this study. The mean average age was 44 ± 3 years (31-60). Seventeen (60.7%) patients were female. Twenty-two (78.5%) patients had hypertension and 9 (32.1%) patients had diabetes mellitus. Aneurysm was examined by using ultrasonography to reveal the flow dynamics. The aneurysm was resected and an appropriate sized graft was interposed under local anesthesia. The same vein was dissected and anastomosed over the graft in an end-to-side fashion. Results Mean aneurysm diameter was 40 ± 12 mm. All aneurysm tissues and thrombotic materials were removed from the surgical field. Mean graft length was 37 ± 11 mm. Three (10.7%) patients need surgical revision because of postoperative bleeding. Dermal necrosis occurred in 1 (3.5%) patient. Infection was noted in 1 (3.5%) patient. Vascular access was started from the reconstructed venous area 2 or 4 days later in all patients. The patency rate was 100% in three years. Conclusions Surgical reconstruction of the arteriovenous fistula aneurysm can be safely performed in hemodialysis patients with low complication rates. It gives early vascular access with high patency rates. All patients are relieved from pain and distended mass effect.