Bora Farsak

Preoperative Fibrinogen Levels as a Predictor of Postoperative Bleeding after Open Heart Surgery

BACKGROUND Open heart surgery still involving major bleeding continues to be a major challenge after cardiac surgery and is also a significant cause of morbidity and mortality. Most hemostatic factors are intercorrelated with postoperative bleeding, and fibrinogen seems the most fundamental hemostatic risk factor for open heart surgery. METHODS The study included 97 patients who underwent elective coronary artery surgery (78 men and 19 women; mean age, 60.9 +/- 10.3). Preoperative blood samples were obtained and preoprative quantitative determination of plasma fibrinogen levels were measured by the clotting method of Clauss using the fibrinogen kit. Patients were operated on by the same team and the same technique. The total amount of drainage blood from chest tubes was recorded after termination of operation. RESULTS There were statistical significance between the fibrinogen levels and the drainage (r = -0.897, P < .001). Chest drainage was a mean of 972 mL (range, 240-2445 mL) in the first 48 hours after sternotomy closure. Fibrinogen level and relation to age was statistically significant (P = .015). There was no statistical significance between fibrinogen levels and gender (male gender = 400.7 +/- 123.0 versus female gender = 395.6 +/- 148.1; P = .877) and between drainage and gender (male gender = 968.2 +/- 538.5 versus female gender = 990.0 +/- 554.7; P = .876). Two patients (2%) died early after the surgery. There were no significant differences between the postoperative bleeding and cardiopulmonary bypass time (P = .648) or cross-clamp time (P = .974). CONCLUSION The results of this study suggested that low preoperative fibrinogen level appears to be a useful diagnostic marker to assess the activity of the coagulation system, and that its preoperative level may serve as a potential risk factor for postoperative bleeding after coronary artery bypass surgery.

Predictive significance of plasma levels of interleukin-6 and high-sensitivity C-reactive protein in atrial fibrillation after coronary artery bypass surgery.

BACKGROUND Postoperative atrial fibrillation (AF) plays a major role in the determination of hemodynamic deterioration and can be associated with cardiovascular events after coronary artery surgery. Elevated interleukin (IL)-6 and C-reactive protein (CRP) levels in patients with AF suggest a role of inflammation in the pathogenesis of AF. We conducted a study to investigate the correlation between postoperative AF and IL-6 and high-sensitivity CRP (hsCRP). MATERIALS AND METHODS Forty-nine patients with a mean age of 60.3 +/- 10.7 years were enrolled in this study. Preoperative and postoperative first day blood samples were collected to assess the IL-6 and hsCRP levels. IL-6 levels were measured by enzyme-linked immunosorbent assay, and hsCRP was measured by rate turbidimetry method. RESULTS Fourteen patients (28.5%) developed AF postoperatively. Patients who developed AF showed elevated serum concentrations of postoperative first day IL-6 (P < .001), preoperative hsCRP (P < .005), and postoperative first day hsCRP (P < 0.001). Preoperative hsCRP levels (P < .002) and postoperative first day IL-6 (P < .001) and hsCRP (P < 0.001) levels were associated with prolonged endotracheal intubation time. Prolonged intensive care unit stay showed significant correlations with elevated levels of preoperative hsCRP (P < 0.002) and postoperative first day IL-6 (P < 0.001) and hsCRP (P < 0.001). There was also statistical significance between the AF+ and AF- groups regarding intensive care unit stay and endotracheal intubation times (P < .001 and P < .001, respectively). Cut-off points for postoperative first day IL-6, preoperative hsCRP, and postoperative first day hsCRP were 46.4 pg/mL (sensitivity = 92.9% and specificity = 80%), 0.46 mg/L (sensitivity = 71% and specificity = 75%), and 17.9 mg/L (sensitivity = 92.9% and specificity = 78%), respectively. CONCLUSIONS Elevated IL-6 and hsCRP levels in patients with postoperative AF suggest inflammatory components have a role of in the pathogenesis of AF.

Clinical performance and biocompatibility of poly(2-methoxyethylacrylate)-coated extracorporeal circuits

BACKGROUND Poly(2-methoxyethylacrylate) is an amphiphilic organic polymer consisting of a hydrophobic backbone with pendant hydrophilic groups that has been reported to reduce protein and platelet adsorption in in vitro and ex vivo studies. METHODS Sixty patients undergoing three-vessel coronary artery bypass grafting were divided into two equal groups. Group 1 had operation with Capiox poly(2-methoxyethylacrylate) coated SX18R oxygenators with noncoated circuits, and group 2 had operation with all noncoated circuits. Hemodynamic variables, blood and urine test results, hematologic variables, complement fractions, C3a and C4d, and interleukin-6 levels were documented preoperatively (T1), on cardiopulmonary bypass (T2), before cessation of cardiopulmonary bypass (T3), after protamine sulfate reversal (T4), and on the first postoperative day (T5). Protein electrophoresis was performed at T1 and T5. Blood cell adhesion and aggregation on fibers were analyzed with optical microscopy, and desorbed protein was evaluated quantitatively by a spectrophotometer using samples obtained when the oxygenators were dismantled after cardiopulmonary bypass. RESULTS Platelet counts in group 1 demonstrated significant differences at T3, T4, and T5 (p < 0.05) versus group 2 and white blood cell counts in group 1 versus group 2, at counts T4 and T5. Albumin levels were significantly better preserved in group 1 at T4, and T5 and fibrinogen levels, at T3 and T5 (p < 0.05). On electrophoresis, the postoperative albumin level was 57.9% +/- 3% in group 1 versus 50.2% +/- 3% in group 2 (p < 0.05). Postoperative hemorrhage was 452 +/- 35 mL in group 1 and 612 +/- 35 mL in group 2 (p < 0.05). Duration of intubation was significantly lower (p < 0.05) in group 1, as was need of blood transfusion (p < 0.01). More platelet adhesion and aggregation were demonstrated on noncoated oxygenator fibers. The amount of desorbed protein was 0.13 +/- 0.01 mg/dL versus 0.012 +/- 0.001 mg/dL (p < 0.001) on noncoated versus coated fibers, respectively. CONCLUSIONS Poly(2-methoxyethylacrylate)-coated oxygenators reduce platelet adhesion, platelet aggregation and protein adsorption. This surface provides a better perioperative clinical status through platelet-, albumin-, and fibrinogen-sparing effects.

Posterior pericardiotomy reduces the incidence of supra-ventricular arrhythmias and pericardial effusion after coronary artery bypass grafting

OBJECTIVE The aim of this prospective study was to demonstrate the effectiveness of posterior pericardiotomy in reducing the incidence pericardial effusions and consequently reducing the related supraventricular tachyarrhythmias and development of delayed posterior cardiac effusions. METHODS This prospective randomized study was carried out in 150 patients undergoing coronary artery bypass grafting in Bayindir Hospital Department of Cardiovascular Surgery between April 2000 and October 2001. One hundred and fifty patients were divided into two groups; each group included 75 patients. A 4-cm longitudinal incision was made parallel and posterior to the left phrenic nerve, extending from the left inferior pulmonary vein to the diaphragm in posterior pericardiotomy group (group I). Posterior pericardiotomy was not performed in conventional treatment group (group II). RESULTS Atrial fibrillation was developed in seven patients (9.3%) in group I and in 24 patients (32%) in group II (P<0.001). Atrial flutter and other supraventricular tachyarrhythmia (SVT) prevalence was not statistically significant. Early pericardial effusion was developed 42.6% (32/75) and 10.6% (8/75), respectively, in group II and group I (P<0.0001), but no late pericardial effusion developed in group I despite seven (9.3%) late pericardial effusions developing in group II (P<0.013). CONCLUSION Posterior pericardiotomy is a simple, safe and effective technique for reducing not only the prevalence of early pericardial effusion and related atrial fibrillation but also delayed posterior pericardial effusion and tamponade.

Angiographic Assessment of Sequential and Individual Coronary Artery Bypass Grafting

Abstract  Objective: In trying to answer the question about the controversial use of sequential grafts, we determined the mid‐term angiographic outcome of patients in whom coronary artery bypass was performed with different types of vein grafts. Methods: A total of 1034 coronary anastomoses on 724 saphenous vein grafts (SVGs) (apart from 497 left internal mammarian artery (LIMA) anastomoses) were assessed in 509 patients in an average of 55.4 ∓ 17.6 months after coronary artery bypass grafting. Results: The patency rates of sequential conduits were markedly higher than those of individual ones (86.6% vs 69.6%, p = 0.0001). Also, the anastomoses on the sequential conduits had better patency rates (80.6% vs 69.6%, p = 0.0001). This difference was even more pronounced in coronary arteries of poor quality/small (<1.5 mm) diameter (68.9% vs 51.6%) for the sequential and individual grafts, respectively (p = 0.03). Also, the patency of the entire sequential conduit was lower when most distally located anastomosis was of poor runoff (45.2%). Conclusions: The patency of a sequential vein conduit is generally superior than that of an individual one, especially for poor runoff coronary vessels, provided that the most distally located anastomosis is performed on a good coronary artery in terms of quality and diameter. Using a minimal length of SVG is another advantage. However, failure of a single sequential conduit jeopardizes all of the anastomoses along that graft segment. Besides, being technically more demanding, technical expertise in performing a sequential anastomosis is probably among the important predictors of patency. (J Card Surg 2003;18:524‐529)

Cervical aortic arch with aneurysm formation

Cervical aortic arch is a very rare anomaly presented as a pulsatile mass on the neck and usually with symptoms of dysphagia, cough and hoarseness. Rarer than the cervical aortic arch, is the aneurysm formation and, despite the equal sex distribution of cervical aortic arch, aneurysm formation always occurs in young females with only nine cases reported. We report herein a 24-year-old woman, diagnosed as cervical aortic arch with aneurysm formation due to basophilic degeneration, treated successfully with surgical intervention. To our knowledge no similar case has been reported.

An unusual experience with posterior pericardiotomy

There are some recent reports on the effect of posterior pericardiotomy to the postoperative supraventricular tachyarrythmias (SVT). Although controversy still exists on its effect on atrial ®brillation, its clinical bene®t on pericardial tamponade is satisfactory [1±3]. To test its effectiveness on SVT we started performing posterior pericardiotomy where we experienced an unusual case on the 29th patient. A 55 year old man with left main coronary stenosis besides two vessel disease, normal ventriculography and ejection fraction 65% was operated in standard fashion with a roller pump, non-pulsatil ̄ow (2.0±2.4 l/min), Polystan membrane oxygenator, 328C systemic hypothermia, single cross clamp, initial antegrade 1 retrograde cold blood cardioplegia, repeated cold retrograde blood cardioplegia every 20 min, and a hot shut before the removal of the cross clamp. LIMA grafting to the LAD and sequantial saphenous graft to ®rst diagonal, intermediate and obtuse marginal arteries were performed. After an uneventful operation ( £ clamp time 42 min, total perfusion time 58 min) the patient was placed in the ICU ward where the patient deteriorated with lateral ST elevation and multifocal ventricular arrhythmias, which did not respond to the medical therapy, continued with ventricular ®brillation (VF), which also did not respond to de®brillation. The patient returned to the operating room urgently and re-explored. After reopening the sternum VF had been over come following the ®rst de®brillation with internal paddles. The hemodynamia returned to normal in a short time with positive inotrops followed by ST normalisation. All the bypass grafts were patent, nothing unusual was observed. Following haemostasis sternum was wired again. But by the time of cutaneous sutures, the ST elevation relapsed, the hemodynamia failed quickly, VF re-occurred. The sternum was reopened in a short time and the heart was de®brillated again. Grafts were patent again, but an ischaemic colour change was observed on the lateral and posterior aspect of the heart. On careful examination we had observed that a segment of saphenous graft (just before and after the intermediate artery anastomosis) and left atrial appendage protruded from the posterior pericardiotomy. The saphenous graft was squeezed by the edges of the posterior pericardiotomy incision. After closing the posterior pericardiotomy incision by primary sutures, and insertion of an intra-aortic balloon from left femoral artery the patient was taken to the ICU ward again. Reperfusion arrhythmia was controlled by amiodorone infusion. Postoperative peak CK-MB (mass) value was 42 ng/ml and Troponin T was 4.85 ng/ml, no Q waves were noted in electrocardiograms. Following an uneventful 5 days in the ICU the patient was discharged in his 10th postoperative day with lateral hypokinesia in echocardiography taken on the 8th day postoperatively. Posterior pericardiotomy is effective on early and late pericardial tamponade, can be effective on the incidence of SVT, but after this case in our opinion, should carefully be used with patients in whom posterior wall revascularization was performed especially by sequential grafting.

Attenuation of ischemia--reperfusion injury by enalapril maleat.

1. The aim of this study was to investigate the effects of enalapril maleate on ischemia-reperfusion injury of the myocardium, after cardioplegic arrest in isolated guinea pig hearts, in a modified Langendorff model. 2. Animals were subjected to 90 min of normothermic global ischemia, followed by 30 min of reperfusion. Cardioplegic arrest was achieved by administering St. Thomas Hospital cardioplegic solution (STHCS). 3. The hearts were randomly allocated into four groups (n=8 in each group). The first group was utilized as control. In the second group, oral pretreatment was made (0.2 mg/kg enalapril maleat was given twice a day for 10 days). In the third group, enalapril maleat (1 micromol/l) was added to STHCS. In the fourth group, hearts were arrested with enalapril maleat-enriched STHCS, and enalapril maleat-enriched (1 micromol/l) Krebs-Henseleit solution was applied during the reperfusion period. 4. Although the study groups showed better recovery of contractility than did the control group, in the last group, the hearts had the best recovery of left ventricular systolic function, where dp/dt maximum was 89.7+/-6.9% of the preischemic values. Group 1, group 2 and group 3 achieved 44.2+/-4.5%, 79.4+/-5.8% and 68.1+/-6.7% of their preischemic dp/dt values. A similar observation was found for left ventricular developed pressure (LVDP); LVDP values were 52.4+/-2.1% (in group 1), 79.6+/-2.8% (in group 2), 72.8+/-4.6% (in group 3) and 86.7+/-5.8% (in group 4) of control after reperfusion. Creatine kinase leakage was significantly lower and postischemic coronary flows were significantly higher in group 4. 5. We concluded that usage of enalapril maleat in the reperfusion period was more effective for improving myocardial recovery after cardioplegic arrest. The additional protective effects of enalapril maleat not only were by angiotensin-converting-enzyme-inhibition-dependent coronary vasodilation and thiol-dependent limitation of oxidative injury, but could also be related to an oxygen-free-radical-scavenging effect.

Clinical and biomaterial evaluation of hyaluronan-based heparin-bonded extracorporeal circuits with reduced versus full systemic anticoagulation in reoperation for coronary revascularization.

Objective This prospective randomized study compares full and reduced heparinization on novel hyaluronan-based heparin-bonded circuits vs. uncoated controls under challenging clinical setting including biomaterial evaluation. Methods 100 patients undergoing reoperation for coronary artery bypass grafting were allocated into two equal groups (n = 50): Group one was treated with hyaluronan-based heparin bonded preconnected circuits (Vision HFOGBS, Gish, California, USA) and Group two with identical uncoated controls (Vision HFO, Gish, USA). In the study group, half of the patients (n = 25) received low-systemic heparin (125 IU/kg, ACT >250 s) or full dose like control group. Blood samples were collected after induction of anesthesia (T1) and heparin administration before cardiopulmonary bypass (CPB) (T2), 15 min after initiation of CPB (T3), before cessation of CPB (T4), 15 min after reversal with protamine (T5), and the first postoperative day at 08: 00 h (T6). Results Platelet counts were preserved significantly better at T5, T6 in hyaluronan groups (P < 0.05 vs. control). Serum IL-2 levels were significantly lower at T4, T5 in both hyaluronan groups and C3a levels at T4 and T5 only in low-dose group (P < 0.05). Troponin-T levels in coronary sinus blood demonstrated well preserved myocardium in hyaluronan groups. No significant differences in thrombin–antithrombin levels were observed between full and low-dose heparin groups at any time point. Amount of desorbed protein was 1.41 ± 0.01 in full and 1.43 ± 0.01 in low dose vs. 1.78 ± 0.01 mg/dl in control (P < 0.05). Conclusion Hyaluronan-based heparin-bonded circuits provided better clinical outcome and less inflammatory response compared with uncoated surfaces. Reduced systemic heparinization combined with hyaluronan-based heparin-bonded circuits is feasible and clinically well tolerated.

SUBXIPHOID APPROACH FOR TREATMENT OF PERICARDIAL EFFUSION

Subxiphoid pericardiotomy was the primary treatment in 305 patients with pericardial effusion from January 1984 to June 1996. There were 198 males and 107 females, ages ranged from 15 days to 75 years. The procedure was carried out with local anesthesia and sedation in 263 (86.2%) patients and under general anesthesia in 42 (13.8%). Median drainage was 975.25 ± 48.46 mL in 264 patients with benign effusion and 1131.25 ± 97.48 mL in 41 (13.4%) with malignant disease; cytology was positive in 14 of 38 (36.8%) and pericardial biopsy showed cancer in 12 of 36 (33.3%). Intraoperative complications in 22 patients (7.2%) included cardiac arrest in 12 (3.9%) of whom, 7 (2.3%) died. Overall 30-day mortality was 16.3%; it was 46.3% (19/41) in malignant cases versus 11.7% (31/264) in cases of benign effusion. Follow-up of 234 (91.8%) hospital survivors for 18 ± 3.62 months (range, 2 to 54 months) showed recurrent pericardial effusion needing further intervention in 31 (13.2%) of whom, 8 had cancer and 23 had benign disease. Median survival in benign cases was more than 107 days versus 56 days in malignant cases. Because of its acceptable mortality and morbidity, subxiphoid pericardiotomy is recommend as an initial procedure.