Bülent Mert

Time from cardiac catheterization to cardiac surgery: a risk factor for acute kidney injury?

OBJECTIVES Acute kidney injury can occur after cardiac catheterization and cardiac surgery. The negative effects of the contrast media and cardiopulmonary bypass on renal function may be additive when performed in close succession. The results in the literature are, however, conflicting. METHODS Preoperative, operative, perioperative and postoperative variables of 573 consecutive adult patients who underwent cardiac surgery on cardiopulmonary bypass were collected prospectively. Acute kidney injury (AKI) was defined according to the Acute Kidney Injury Network criteria based on changes in serum creatinine level within 48 h of surgery. RESULTS Acute kidney injury was detected in 233 patients (41%). In a multivariate analysis, older age (P = 0.01), longer cardiopulmonary bypass time (P = 0.003), lower preoperative haematocrit level (P = 0.02) and higher body mass index (P = 0.001) were found to be independently associated with development of acute kidney injury. Analysis of the time from cardiac catheterization to surgery by logistic regression modelling did not show any significant change in the risk of acute kidney injury. Risk related to time from catheterization to surgery was not increased even in the patients with elevated preprocedural creatinine levels (>106 μmol l(-1); P = 0.23), left ventricular dysfunction (ejection fraction <40%; P = 0.19) and older age (≥70 years; P = 0.86). CONCLUSIONS The time from cardiac catheterization to cardiac surgery is not a risk factor for the development of postoperative acute kidney injury even in patients with other risk factors. Surgical intervention should not be delayed in emergency or urgent cases. The optimization of renal function seems to be the correct strategy in clinically stable patients with risk factors for acute kidney injury.

A New Use of Fogarty Catheter: Chest Tube Clearance

Chest tubes are commonly used for patients who have undergone a cardiothoracic procedure to avoid the complications related to the accumulation of blood and serous fluid in the chest. Although the traditional methods such as milking, stripping or active chest tube clearance devices are used to establish patency of the chest tubes, they can become clogged at any time after their placement. Our technique may re-establish the tube patency with utilising Fogarty catheter and without any detriment to tissues.

Radiofrequency Ablation for Atrial Fibrillation in Rheumatic Valvular Disease

BACKGROUND We have reviewed the results of radiofrequency ablation (RFA) in patients with rheumatic valve disease. METHODS Sixty-seven patients underwent operation for rheumatic valvular disease and RFA concomitantly with the planned procedure. Twenty-two (32.8%) were male and 45 (67.2%) female. The mean duration of atrial fibrillation (AF) was 47.4+/-30.4 months (12-192). Logistic regression test was used to perform a risk factor analysis. RESULTS Two patients died postoperatively (3.0%) and 3 died in the follow-up period (4.5%). One patient (1.5%) required permanent pacemaker. During the hospitalisation, 24 patients (35.8%) had AF but 6 of them returned to the normal sinus rhythm by the time of discharge. Forty-nine patients (73.1%) were discharged with normal sinus rhythm. The mean duration of follow-up was 15.1+/-15.2 months (0-59). Six patients (9.0%) had recurrent AF during the follow-up period. For early AF recurrence male sex was a significant risk factor (p=0.028) with an odds ratio 8627 (CI 95% 1261-59,006). CONCLUSIONS The low sinus rhythm rate at discharge and high rates of recurrence may be attributed to the disease nature. Males are at increased risk of early AF recurrence but no significant risk factors for late recurrence have been found.

Popliteal artery pseudoaneurysm associated with solitary osteochondromatosis

Osteochondroma is the most common benign tumor of the bone, seen mostly during adolescence. In the current study, we report a 19-year-old male patient with a two-week history of pain and swelling of the medial side of his right thigh just above the knee without any trauma. CT angiography revealed a popliteal artery pseudoaneurysm and its close relationship with a femoral osteochondroma. Surgical repair consisted of repair of pseudoaneurysm and removal of osteochondroma. In young patients, a non-traumatic pseudoaneurysm of distal femoral artery may be a complication of an osteochondroma and this treatable pathology should be looked for to prevent recurrence.

Impact of coronary collateral circulation and severity of coronary artery disease in the development of postoperative atrial fibrillation

OBJECTIVES Atrial fibrillation (AF) after cardiac surgery has been reported to be approximately 30%, making it one of the most important causes of morbidity and mortality post surgery. Although various clinical and laboratory predictors and underlying mechanisms progressing to postoperative AF have been proposed, the role of ischaemia in pathogenesis is doubtful. In this study, the association of coronary collateral circulation (CCC) and severity of coronary artery disease (CAD) with the development of postoperative AF was investigated. METHODS A total of 597 patients who underwent on-pump coronary artery bypass surgery were included in the study. Pre-, peri- and postoperative variables were recorded in a computerized database. CCC and severity of CAD were documented for each patient according to Rentrop classification and Gensini score. RESULTS Postoperative AF was observed in 96 patients (16.1%). Advanced age, female gender, presence of hypertension and low haematocrit level were significantly associated with postoperative AF. By contrast, CCC and severity of CAD were not associated with postoperative AF (P = 0.22 and 0.5, respectively). Older age and lower preoperative haematocrit levels were the major predictors of postoperative AF development in the multivariate regression analysis. CONCLUSIONS CCC and severity of CAD did not have a significant effect on the occurrence of postoperative AF, suggesting an ineffective role of myocardial ischaemia in the development of this condition.

Ruptured Abdominal Aortic Aneurysm Causing Severe Erosion in the Lumbar Vertebral Body

Erosion of a vertebral body related to continuous pulsatile compression by an abdominal aortic aneurysm is quite rare. Behçet’s disease is found to be coexistent in most of the cases. A 70 year old male patient was admitted to our clinic with complaints of intense lower back pain that had been persistent for a few weeks. He recalled that a duller back pain had been present for about 6 months previously. He had no history of Behçet’s disease, and no oral or genital ulcers was found to be present. On physical examination, a pulsatile abdominal mass was found. Serological and pathological tests were negative for Behçet’s Disease and all further laboratory work-up was found to be normal. Further examination with computed tomography angiography revealed a ruptured abdominal aortic aneurysm, beginning 1 cm inferior to the renal arteries and extending down to involve both common iliac arteries. The maximum diameter of the aneurysm was 5.5 cm and a posterior rupture was detected just anterior to the third lumbar vertebra with concomitant erosion of the vertebral body. The patient underwent an emergency operation for repair of the ruptured aneurysm. When the aneurysm was dissected, a rupture causing a 3x4 cm defect on the posterior wall of the abdominal aorta was found. Severe erosion of the lumbar vertebral body was visible just posterior to this ruptured section of the aneurysm. Aorta bifemoral bypass grafting was performed. The patient recovered without any incidents and was discharged on the sixth postoperative day. Despite the rarity of vertebral erosion in abdominal aortic aneurysms, non-coexistence of Behçet’s Disease is much rarer, as in our case. It may be caused by continuous, pulsatile pressure of the chronic abdominal aneurysmal sac on the osteoporotic, loosened bone tissue in these patients. If lack of the anterior column support could result in future instability, reconstruction and various operations on the vertebra may be necessary in these patients. Under emergency operation for the rupture of the abdominal aorta, no further emergency intervention was found to be necessary for the vertebral column in our patient. Following his discharge, elective operation was planned for the possible danger of instability of the anterior column in the future due to the resultant defect in the lumbar vertebral body. Although mostly detected in Behçet’s Disease, vertebral erosion could be present also in the aged patient group. In the differential diagnosis of lower back pain, abdominal aortic aneurysm and the rarer condition of concomitant vertebral erosion should be kept in mind in these patients. (JAREM 2011; 1: 72-3)