Erkan Kuralay

Missed arterial injuries in military patients

BACKGROUND Military vascular injuries frequently result from fragment wounds while civilian vascular injuries usually are caused by gunshot wounds. The natural history of untreated major injuries by small low velocity fragments is not well known. This study evaluated the nature of these wounds. METHODS From 1990 to 1995, 40 patients with a delayed diagnosis of an arterial injury in the extremity, abdomen, or neck were treated. The median delay between injury and diagnosis was 60 days. All patients had been seen at other military hospitals immediately after trauma. RESULTS During initial hospitalization, immediate exploration had been performed in 23 patients and arteriogram in 3 patients. According to analysis of the records of patients, none of them had hard signs of vascular injury at the time of initial evaluation after trauma. Complications of missed arterial injuries included the following: false aneurysm, 21 (52.5%); arteriovenous fistula, 14 (35%); and occlusion, 5 (12.5%). The superficial femoral artery (n = 11) was the most commonly injured vessel. The remaining arteries included the following: carotid, 2; vertebral, 1; subclavian, 5; axillary, 2; brachial, 3; radial or ulnar, 2; internal iliac, 2; common femoral, 1; profunda femoris, 2; popliteal, 1; tibioperoneal, 8. Thirty-eight patients had penetrating wounds (21 fragments, 9 gunshot, 3 shotgun, 5 stab wounds), and only 2 patients had blunt trauma. All patients underwent surgery. There were no deaths and no loss of extremity, but 10 patients had fair results and only 4 patients required later reoperation. CONCLUSION Traumatic arterial injuries that particularly are caused by low-velocity small fragment wounds can result in serious delayed complications months or even years after the injury. Patients with penetrating injuries must be closely monitored, and arteriography is recommended to evaluate the conditions of patients with potential vascular injury even when overt clinical signs or symptoms of vascular injury are absent.

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.

Effect of posterior pericardiotomy on postoperative supraventricular arrhythmias and late pericardial effusion (posterior pericardiotomy)

OBJECTIVE The aim of this prospective study was to evaluate the effectiveness of posterior pericardiotomy from the point of pericardial effusion related with supraventricular tachycardia and development of delayed posterior cardiac effusions. MATERIALS AND METHODS This prospective randomized study was carried out in 200 patients undergoing coronary artery bypass surgery in Gülhane Medical Academy Department of Cardiovascular Surgery between June 1996 and June 1997. Patients were divided into 2 groups; each group included 100 patients. Longitudinal incision was made parallel and posterior to the left phrenic nerve, extending from the left inferior pulmonary vein to the diaphragm in group I patients. Posterior pericardiotomy was not done in group II. RESULTS Atrial fibrillation was developed in 6 patients (6%) in group I and in 34 patients (34%) in group II (P =.0000007). Atrial flutter and other supraventricular arrhythmia prevalence was not statistically significant. Early and late pericardial effusion were developed 54% and 21%, respectively, in group II, but neither early nor late pericardial effusion were developed in group I (P =.00001). Delayed pericardial tamponade was also significantly lower in group I (0% vs 10%; P =.001). CONCLUSION Posterior pericardiotomy is technically easy to perform and a safe and effective technique that reduces not only the prevalence of early pericardial effusion and related atrial fibrillation but also delayed posterior pericardial effusion and tamponade.

Transesophageal Echocardiography in Cardiac Surgical Emergencies

The value and utility of transesophageal echocardiography (TEE) in unstable cardiac surgical patients have been assessed; 119 TEE studies were performed and evaluated in the emergency setting. The studies were performed in the cardiac surgical intensive care unit (n = 62) and in the operating room (n = 57). There were 81 men and 38 women with a mean age of 58.2 years. The indications for TEE were as follows: hypotension refractory to conventional treatment (n = 83); prosthetic or native valve dysfunction (n = 25); and suspected aortic dissection (n = 10). TEE provided valuable diagnostic information in 107 patients and was completely normal in 12 patients. Based on these results 22 patients had urgent surgical intervention without further studies. The average time to diagnosis was 11.2 minutes. No significant complications were noted. Our results suggest that TEE is highly diagnostic for most of the abnormalities responsible for hemodynamic instability in the perioperative period and facilitates decision making in cardiac surgical emergencies.

Does Continuous Insulin Therapy Reduce Postoperative Supraventricular Tachycardia Incidence After Coronary Artery Bypass Operations in Diabetic Patients

OBJECTIVE To compare continuous insulin infusion (CII) and intermittent subcutaneous insulin therapy for preventing supraventricular tachycardia. The authors propose that continuous insulin therapy is more effective to reduce supraventricular tachycardias. DESIGN A prospective randomized study. SETTING This study was performed in 2 different centers between April 2005 and February 2007: Gülhane Military Medical Academy and University of Süleyman Demirel. PARTICIPANTS Two hundred diabetic patients were included in this prospective randomized study. Patients were divided into 2 groups according to their insulin therapy in 2 different centers. INTERVENTIONS Group 1 included 100 diabetes mellitus (DM) patients, and CIIs were administrated. These patients received a CII infusion titrated per protocol in the perioperative period (Portland protocol). Group 2 also included 100 DM patients, and subcutaneous insulin was injected every 4 hours in a directed attempt to maintain blood glucose levels below 200 mg/dL. Sliding scale dosage of insulin was titrated to each patients glycemic response during the prior 4 hours. MEASUREMENTS AND MAIN RESULTS There were 5 hospital mortalities in the intermittent insulin group. The causes of death were pump failure in 3 patients and ventricular fibrillation in 2 patients. There were 2 hospital mortalities in the CII group (p = 0.044). Thirty-six patients in the intermittent insulin group and 21 patients in the CII group required positive inotropic drugs after cardiopulmonary bypass (p = 0.028). Low cardiac output developed in 28 and 16 patients in the intermittent and CII groups, respectively (p = 0.045). Univariate analysis identified positive inotropic drug requirement (p = 0.011, odds ratio [OR] = 3.41), ejection fraction (EF) (p = 0.001, OR = 0.92), cross-clamp time (p = 0.046, OR = 0.97), left internal mammary artery (p = 0.023, OR = 0.49), chronic obstructive pulmonary disease (COPD) (forced expiratory volume in 1 second <75% of predicted value (p = 0.009, OR = 2.02), intra-aortic balloon pump (p = 0.045, OR = 1.23), body mass index (p = 0.035 OR = 5.60), and CII (p < 0.001, OR = 0.36) as predictors of SVT. Stepwise multivariate analysis confirmed the significance of some of the previously mentioned variables as predictors of SVT. The value of -2 log likelihood of multivariate analyses was 421.504. These were EF (p < 0.001, OR = 0.91), positive inotropic drug requirement (p < 0.001, OR = 3.94), COPD (p = 0.036, OR = 2.11), and CII (p < 0.001, OR = 0.19). CONCLUSION Continuous insulin therapy in the perioperative period reduces infectious complications, such as sternal wound infection and mediastinitis, cardiac mortality caused by pump failure, and the risk of development of supraventricular tachycardias.

Postoperative use of aprotinin in cardiac operations: An alternative to its prophylactic use

BACKGROUND Aprotinin reduces blood loss after cardiopulmonary bypass. Although there can be little doubt about the efficacy of aprotinin, its safety has been questioned recently and is still under investigation. Because of the potential for complications and the high cost, a selective strategy limiting drug delivery to patients with established postoperative bleeding will be more reasonable. METHODS In a prospective, randomized, double-blind trial we studied the effect of postoperative low-dose (2 million kallikrein inactivator units) aprotinin on blood loss and transfusion requirements in patients undergoing cardiopulmonary bypass. Fifty-seven patients were randomly assigned to two groups: aprotinin or placebo. RESULTS The two groups were comparable in all demographic and surgical variables. Postoperative chest tube drainage was significantly less in the aprotinin group than in the placebo group (410 ml vs 696 ml, p < 0.01). The use of homologous blood products was significantly less in the aprotinin group than in the placebo group (0.4 +/- 0.5 unit vs 1.7 +/- 0.9 unit for packed red blood cells and 0.8 +/- 1.3 unit vs 2.3 +/- 1.6 unit for fresh frozen plasma). CONCLUSIONS Our results suggest that postoperative aprotinin reduces blood loss and transfusion requirements and provides the opportunity to restrict its use selectively to patients with excessive postoperative bleeding.

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)

Postoperative aprotinin: Effect on blood loss and transfusion requirements in cardiac operations

BACKGROUND Aprotinin has been used increasingly to reduce postoperative blood loss in open heart operations. Although it was reported as safe in earlier studies, the overall safety of prophylactic use has been questioned recently. Because of the potential for complications and the high cost, it will be reasonable to use aprotinin more selectively in the postoperative period. METHODS We prospectively studied the effect of postoperative low-dose aprotinin (2 million kallikrein inactivator units [280 mg]) on blood loss and transfusion requirements in patients undergoing cardiopulmonary bypass. Seventy-five patients were randomly assigned to three groups: prophylactic high-dose aprotinin (group 1), postoperative aprotinin (group 2), or a nonmedicated control group (group 3). RESULTS The three groups were comparable in all demographic and operative variables. Postoperative chest tube drainage was significantly decreased in both aprotinin groups compared with that in the control group (295 mL in group 1 and 325 mL in group 2 versus 411 mL in group 3; p < 0.05). No significant difference was seen between the two aprotinin groups. The use of homologous blood products was significantly less in group 1 and group 2 than in group 3 (1.15 +/- 1.13 U and 1.35 +/- 1.30 U versus 2.55 +/- 1.09 U; p < 0.05). CONCLUSIONS Our results suggest that postoperative aprotinin reduces blood loss and transfusion requirements comparably with prophylactic high-dose aprotinin. Thus, one can restrict its use to patients with excessive postoperative bleeding.

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.