Erkan İlhan

Incidence, risk factors, and outcomes of perioperative acute kidney injury in noncardiac and nonvascular surgery

BACKGROUND The aim of this study was to determine the incidence rate, identify the risk factors, and describe the clinical outcome of perioperative acute kidney injury (AKI) in patients undergoing noncardiac, nonvascular surgery (NCS). METHODS A total of 1,200 adult consecutive patients undergoing NCS were prospectively evaluated. Patients with pre-existing renal dysfunction were excluded. The primary outcome of this study was perioperative AKI defined by the RIFLE (risk, injury, failure, loss of function, and end-stage kidney disease) criteria. RESULTS Eighty-one patients (6.7%) met the AKI criteria. Multivariate analysis identified age, diabetes, revised cardiac risk index, and American Society of Anesthesiologists physical status as independent predictors of AKI. Patients with AKI had more cardiovascular (33.3% vs 11.3%, P < .001) complications and a higher in-hospital mortality rate (6.1% vs 0.9%, P = .003) compared with patients without AKI. CONCLUSIONS Several preoperative predictors are found to be associated with AKI after NCS. Perioperative AKI is an independent risk factor for outcome after NCS.

Coronary artery fistula: Review of 54 cases from single center experience*

BACKGROUND Demographic and clinical characteristics and angiographic findings of Turkish patients with coronary artery fistula have been investigated in this study and diagnostic tests and treatment methods used in these patients have also been evaluated in detail. METHODS We have examined the cardiac catheterization laboratory database retrospectively between March 2006 and July 2010. Among 49,567 patients, we have noted 60 patients diagnosed as coronary artery fistula. After coronary angiographic images were evaluated by two invasive cardiologists, 54 patients who had clear evidence of vessel of origin and drainage were included in the study. RESULTS A total of 54 (0.1%) patients with coronary artery fistula were noted. Mean age was 56.7 ± 10.7 years; 42 out of 54 patients had accompanying cardiac disorders. Patients complaints were directly associated with the presence of the fistula. Chest pain was the admission symptom in all of the patients with isolated coronary artery fistula. Six patients had coexistent congenital anomalies. Myocardial infarction with ST segment elevation occurred in 11 of the patients. In contrast to the previous reports, the most common artery of origin of the fistula was left anterior descending artery (50.8%) and pulmonary artery was found to be the most frequent region of the fistula drainage by 53.7%. CONCLUSIONS Our findings suggest that large fistulas originating from the proximal segments of coronary arteries may increase the likelihood of atherosclerosis and myocardial infarction even in asymptomatic patients with no evidence of ischemia in noninvasive tests and no dilatation of cardiac chambers, and should therefore be closed.

Kounis Syndrome secondary to cefuroxime axetil use in an asthmatic patient

A sixty-one year old female with a past history of asthma was admitted to the emergency department because of vertigo, nausea, vomiting, chest pain and generalized erythema after taking an oral dose of cefuroxime axetil. Electrocardiography showed ST segment elevation in inferior leads. After coronary angiography, type 2 variant of Kounis Syndrome is diagnosed. We present first drug induced Kounis Syndrome in an asthmatic patient with severe anaphylactic shock. The present report also shows that atopic people expressing an amplified mast cell degranulation may have more serious hemodynamic decompensation during hypersensitivity reactions.

Cannabis: a rare trigger of premature myocardial infarction.

Video 1. 3D echocardiogram showing sinus Valsalva aneurysm. Video 2. Aortography showing ruptured sinus Valsalva and regurgitation into the right atrium. Video 3. Cine X-ray graphy showing the release of the closure device. Video 4. Aortography showing complete closure of the defect and absence of regurgitation. Video 5. Transesophageal echocardiography showing the closure device after deployment.

Acute Aortic Regurgitation with Myocardial Infarction: An Important Clue for Aortic Dissection

BACKGROUND Aortic dissection is an important cause of acute chest pain that should be rapidly diagnosed, as mortality increases with each hour this condition is left untreated. The diagnosis can be challenging, especially if concomitant myocardial infarction is present. Echocardiography is an important tool for the differential diagnosis. OBJECTIVES To stress the importance of recognizing aortic regurgitation for the differentiation of myocardial infarction and aortic dissection. CASE REPORT An 80-year-old woman was admitted to our hospital with chest pain that was diagnosed as inferior and lateral wall myocardial infarction based on electrocardiographic findings. The diagnosis was reevaluated when aortic regurgitation was detected on echocardiography. Closer inspection of the ascending aorta revealed a dissection flap as the cause of aortic regurgitation. CONCLUSION Detection of aortic regurgitation in a patient with myocardial infarction and normal valves should prompt the search for a possible aortic dissection, whether or not the dissection flap can be visualized.

Predictive value of red cell distribution width in intrahospital mortality and postintervention thrombolysis in myocardial infarction flow in patients with acute anterior myocardial infarction.

ObjectivesRecent studies have reported a strong independent association between increased red cell distribution width (RDW) and the risk of adverse outcomes in patients with heart failure, stable coronary disease, and acute coronary syndromes. However, in this study we aimed to determine the impact of an elevated RDW level on the postinterventional thrombolysis in myocardial infarction (TIMI) flow and intrahospital mortality in patients with acute anterior myocardial infarction (AMI). MethodsA total of 763 patients with acute AMI undergoing a primary percutaneous coronary intervention were evaluated retrospectively. Upon admission, the RDW level was measured by an automated complete blood count. Postinterventional TIMI flow and intrahospital mortality was documented for all patients from hospital registries. The patients were classified according to the RDW level. RDW more than 14.8% was defined as elevated RDW. All groups were compared statistically according to the preinterventional characteristics. ResultsElevated RDW was found to be an independent predictor of increased intrahospital mortality in multivariate regression analysis (hazard ratio: 3.677, 95% confidence interval: 1.228–11.008, P=0.02). Other independent predictors for intrahospital mortality were diabetes mellitus (hazard ratio: 6.743, 95% confidence interval: 1.941–23.420, P=0.003), smoking (hazard ratio: 6.779, 95% confidence interval: 1.505–30.534, P=0.013), and creatinine more than 0.8 mg/dl (hazard ratio: 7.982, 95% confidence interval: 1.759–36.211, P=0.007). However, there were no independent predictors for TIMI including elevated RDW. ConclusionA high admission RDW level in patients with acute AMI undergoing a primary percutaneous coronary intervention was associated with an increased risk for intrahospital cardiovascular mortality, but was not associated with worse postinterventional TIMI flow.

Outcome of Noncardiac and Nonvascular Surgery in Patients With Mechanical Heart Valves

There is a tendency to avoid noncardiac surgery in patients with mechanical heart valves (MHVs) owing to the increased risk of perioperative thromboembolism, infective endocarditis, and bleeding. We aimed to determine the risk of cardiac and noncardiac complications in patients with MHVs who underwent noncardiothoracic, nonvascular surgery. A total of 140 patients with MHVs (77 aortic, 46 mitral, and 17 double valve) and 1,200 patients with native valves (control group) were prospectively followed up for a minimum of 3 months after noncardiothoracic and nonvascular surgery. Patients with bioprostheses were excluded. Those patients aged >18 years who underwent an elective, non-outpatient, open surgical procedure were enrolled. Subcutaneous enoxaparin 1 mg/kg, twice daily, was used as bridging anticoagulation. The demographics, co-morbidities, and preoperative (medications, echocardiographic findings, laboratory results) and postoperative data were evaluated for their association with the occurrence of perioperative adverse events. The incidence of perioperative adverse cardiovascular (10.8% vs 10.7%, p = 0.985) and noncardiovascular (11.9% vs 11.4%, p = 0.989) events was similar in those patients with and without MHVs. Bleeding (18.6% vs 14.2%, p = 0.989), thromboembolism (3.6% vs 2%, p = 0.989), and mortality at 3 months (1.4% vs 1.3%, p = 0.825) were also similar for the 2 groups. In conclusion, with close follow-up and strict adherence to the guidelines, patients with MHVs and patients with native heart valves undergoing noncardiac and nonvascular surgery have a similar risk of mortality and morbidity.

A novel explanation for the cause of atrial fibrillation seen in atherosclerotic coronary artery disease: “Downstream inflammation” hypothesis

Atrial fibrillation is a frequent arrhythmia, and atherosclerotic coronary artery disease remains as the most common etiological factor underlying atrial fibrillation, along with systemic hypertension. The relationship between uncomplicated coronary artery disease and atrial fibrillation is not explained satisfactorily. Inflammation is now recognized as an important pathogenetic mechanism for both disorders. We hypothesise that inflammation originated from atherosclerotic coronary arteries may disseminate downstream to atrial tissue and initiate or stabilize atrial fibrillation. Studies conducted with drugs bearing anti-inflammatory properties such as hydroxymethylglutaryl coenzyme A inhibitors decrease frequency of both conditions. Such a relationship may become a novel therapeutic target to prevent this arrhythmia or decrease the frequency of paroxysms.

Congenital absence of the pericardium: A rare cause of right ventricular dilatation and levoposition of the heart

Congenital absence of the pericardium is a rare cardiac defect with variable clinical presentations and is usually discovered incidentally. The pathology may lead to serious complications such as incarceration of cardiac tissue, myocardial ischemia, aortic dissection or valvular insufficiency. Diagnosis is not difficult so long as some tips are remembered. We present the cases of two patients with congenital absence of left pericardium.

An unusual presentation of pericardial cyst: recurrent syncope in a young patient.

Although pericardial cysts are generally benign structures and detected incidentally, they may be associated with life-threatening complications. We present the case of a 24 year-old man with a giant hemorrhagic pericardial cyst diagnosed after evaluation for recurrent syncope which caused compression of the right ventricle. Spontaneous hemorrhage into a pericardial cyst is an extremely rare event, and to our knowledge this is the first case in which a pericardial cyst has been shown to cause recurrent syncope.