Eylul Kafali

The benefits of continuous ultrafiltration in pediatric cardiac surgery

Background—Systemic inflammatory response and capillary leak syndrome, caused by extracorporeal circulation, have negative effects on the function of vital organs during the postoperative period. Modified ultrafiltration (MUF) has been developed as an alternative method to reduce the detrimental effects of cardiopulmonary bypass. The aim of this prospective, randomized study is to analyze the effects of MUF in a pediatric population undergoing congenital cardiac surgery. Methods—Twenty‐seven patients who underwent open‐heart surgery at our institution were included in this prospective study. They were randomized into two groups as follows: Group I (n=14) of conventional ultrafiltration during bypass and Group II (n=13) receiving both conventional and modified ultrafiltration during and after the cessation of the bypass, respectively. The amount of prime volume, postoperative chest drain loss, transfusion requirements, hemodynamical parameters, duration of mechanical ventilatory support, and length of intensive care unit stay were compared between the two groups. During the postoperative period, the concentrations of hematological, biochemical and inflammatory parameters were also compared by analyzing the blood samples obtained at various time points. Results—MUF resulted in a significant increase in hemoglobin, hematocrit and platelet levels, and significantly reduced the amount of chest tube output and transfused blood and blood products. MUF also shortened the duration of postoperative mechanical ventilatory support, length of the intensive care unit stay and improved postoperative hemodynamical parameters. During the early postoperative hours, IL‐8 is significantly reduced in patients undergoing MUF, however, the concentrations of IL‐8 were similar in both groups at the end of 24 h. Conclusions—MUF decreases the duration of mechanical ventilatory support, the length of intensive care unit stay, the need for blood transfusion and improves postoperative hemodynamics. It is associated with increased levels of hemoglobin, hematocrit and platelets. We can conclude that MUF attenuates the inflammatory response by decreasing the levels of inflammatory mediators.

Peri-operative comparison of different transient external shunt techniques in bidirectional cavo-pulmonary shunt

OBJECTIVE In patients with functional single ventricular physiology, the avoidance of cardiopulmonary bypass offers many advantages including earlier extubation, decreased necessity of inotropic support, improved hemodynamical status and reduced likelihood of post-operative prolonged pleural effusion. We believe that the bidirectional cavopulmonary anastomosis operations may be performed with transient external shunt techniques. The purpose of this prospective study is the peri- and post-operative comparison of different transient external shunt methods used in bidirectional cavopulmonary shunt operations. METHODS Between years 1997 and 2000, 30 patients have undergone bidirectional cavo-pulmonary shunt operation by using three different types of external shunt. The mean patient age was 13 months (range, 3 months-3 years). Previous operations had been performed in ten patients (33%). All patients were divided into three groups according to type of external shunt used. In group A (ten patients), the transient external shunt was constructed between superior vena cava and right atrium by uniting two standard venous cannulas with a Y-connector. In group B (ten patients), the external shunt was performed with a single short venous cannula constructed between superior vena cava and right atrium. In group C (ten patients), the external shunt was constructed between superior vena cava and left pulmonary artery by using a single short venous cannula. During operation, central venous pressure (CVP), arterial O(2) saturation and mean arterial blood pressure were recorded continuously. RESULTS All operations are completed without the establishment of cardiopulmonary bypass. Hospital mortality was 3.3%. One patient in group A died because of low cardiac output at the end of postoperative day 2. All patients were extubated within 4h. In groups A-C mean superior vena caval pressures were measured 28, 24 and 21 mmHg, respectively during superior vena cava-right pulmonary artery anastomosis. In both groups A and B patients, arterial O(2) saturation decreased to a minimum 53+/-2 and 53+/-2%, respectively during the operation. In the group C, minimum arterial O(2) saturation was measured 82+/-2%. Although mean arterial pressure decreased in all groups during clampage; in group C patients, this drop is not significant. CONCLUSION Based on the study presented here, bidirectional cavo-pulmonary anastomosis can be carried out by using different types of transient external shunt. The best hemodynamical condition and arterial O(2) levels were achieved with the shunt constructed between superior vena cava and left pulmonary artery.

Surgery of the carotid artery : Local anaesthesia versus general anaesthesia

Abstract Objective: Carotid artery surgery is safely and commonly performed under general, regional or local anaesthesia. The aim of the study was to compare local and general anaesthesia in carotid artery surgery in order to establish whether differences exist in terms of peri-operative results, use of intra-operative shunts and costs. Methods: We retrospectively reviewed the data on 426 patients who underwent carotid endarterectomy with either local or general anaesthesia at our institution over a four-year period. All available clinical, pathologic and postoperative data were reviewed and analyzed for postoperative results. Surgical indications, outcome, operative techniques, and complications were compared. Results: A total of 306 carotid endarterectomy operations under local, and 127 under general anaesthesia were performed and analyzed. Groups were similar in terms of age, sex and pre-operative risk factor distribution. The local anaesthesia group was associated with a lower incidence of shunt placement and operative time when compared to the general anaesthesia group. Postoperative intensive care unit requirement, hospital stay and costs were also lower with local anaesthesia. Significant difference in neurological complications and mortality rate was not observed between the two groups. Conclusion: Carotid endarterectomy performed under local or general anaesthesia is associated with low morbidity and mortality rates. Local anaesthesia enables the surgeon to assess the neurological status during the procedure. It is also associated with decreased shunt usage, decreased operative time and, in high risk patients, lower intensive care unit requirement and hospital stay.

Visceral artery aneurysms.

OBJECTIVE Visceral artery aneurysms are rare vascular malformations and the literature lacks satisfactory general information about the pathology. The aim of this study was to review our experiences in the diagnosis and treatment of visceral artery aneurysms. MATERIALS AND METHODS We retrospectively reviewed data on 10 patients who were diagnosed with visceral artery aneurysms at our institution between June 2002 and September 2005. All available clinical, pathologic, and postoperative data were reviewed and analyzed for postoperative outcome. RESULTS Four splenic artery aneurysms, 2 hepatic artery aneurysms, 5 renal artery aneurysms, 1 superior mesenteric artery aneurysm, and 1 inferior mesenteric artery aneurysm (13 total visceral artery aneurysms) were diagnosed in 10 patients. All the patients were treated except 1 patient with bilateral renal artery aneurysms. One patient required emergent surgical treatment due to splenic artery aneurysm rupture. Only 1 patient underwent endovascular treatment (ie, coil embolization for a superior mesenteric artery aneurysm); otherwise all the patients were treated surgically on an elective basis. Surgical treatment modalities included ligation with exclusion in 4 patients (2 splenic artery aneurysms, 1 renal artery aneurysm, 1 hepatic artery aneurysm) and resection with revascularization in 4 patients (1 splenic artery aneurysm, 2 renal artery aneurysms, 1 hepatic artery aneurysm, 1 inferior mesenteric artery aneurysm). Histopathologic examination of the vascular materials revealed major atherosclerotic changes except one that showed inflammatory vasculitic changes. One patient required bleeding revision, and mortality did not occur in any of the patients. CONCLUSIONS Visceral artery aneurysms are rare and potentially life-threatening vascular disorders. The number of cases diagnosed every year increases because of advanced radiologic diagnostic methods and screening programs. Careful consideration and early management of these malformations can be life saving.

Aneurysm of the kinked extracranial internal carotid artery case report and review of the literature.

Aneurysms at the extracranial portion of the internal carotid artery are rare disorders. In the largest series, McCollum reported only 37 cases over a 21 year period (1) and Moreau reported 35 cases over a 24 year period (2). This uncommon but interesting vascular disorder usually presents as a parapharyngeal pulsatile mass. It can be partially or completely thrombosed and can thereby cause embolization or compression of neuronal vasculature. Ruptures and ischaemic events are other complications. Therefore the mortality rate in nonoperated patients is very high. The major etiologic factor is atherosclerosis. Sometimes, trauma may be another cause. Surgery is recommended for symptomatic aneurysms in patients at all ages. The aim of this paper is to report the symptoms and clinical findings of a patient with a kinked extracranial internal carotid artery with aneurysm and to review the literature.

Complication of Behcet's Disease: Spontaneous Aortic Pseudoaneurysm

Abstract  Behcets disease is an autoimmune multisystemic disorder based on vasculitis. In this disease, the most important predictor of morbidity and mortality is the vascular complications. Appropriate surgical interventions are critical and must be planned strategically. Here, we will describe a very rare complication of the disease; spontaneous aortic pseudoaneurysm in a 33‐year‐old patient.

A Practical and Effective Approach for the Prevention of Ischemia-Reperfusion Injury after Acute Myocardial Infarction: Pressure-Regulated Tepid Blood Reperfusion

BACKGROUND The prevention of perioperative ischemia-reperfusion injury is of critical importance, and this issue becomes more important in patients undergoing an early emergent revascularization procedure after an acute myocardial infarction. In this study, we sought to test the hypothesis that our simplified pressure-controlled initial reperfusion technique would be protective against ischemia-reperfusion injury in this subgroup of patients. METHODS The data of 20 patients (group I) who underwent an emergent coronary artery bypass grafting procedure were analyzed and compared with the results of 37 patients (group II) underwent an innovative reperfusion technique. In group I patients, the operation was carried out using standard techniques. In group II, after the completion of all anastomoses, reperfusion was initiated before rewarming with a pressure of 20 to 25 mmHg and continued for a 2-minute period. Systemic blood pressure was then gradually increased to 40 mmHg and the aortic root was perfused at this pressure for another 2-minute period. Following the completion of the second low-pressure reperfusion period, cardiopulmonary bypass flow was regulated to preoperatively calculated values until systemic temperature reached 37 degrees C. RESULTS Both groups showed significant differences in terms of cardiac output, arrhythmia rates, and biochemical parameters. Spontaneous sinus rhythm recurred more frequently in group II (P < .01, 86% versus 45%). Atrial fibrillation attacks were observed in 5 and 3 patients in groups I and II, respectively. All patients were medically converted to sinus rhythm with amiadarone and/or beta-blockers. Persistent electrocardiographic changes indicating postoperative myocardial infarction occurred in 5 patients in group I and in 1 patient in group II (P = .003). Postoperative enzyme levels were found to be lower in group II patients and the differences became statistically significant at the end of 24 hours. CONCLUSION These results indicate that our controlled initial reperfusion technique is effective in the prevention of ischemia-reperfusion injury. We advocate the use of this innovative technique as an alternative to complex controlled aortic root reperfusion with the guidance of the early promising results of this study.

Comparison of 3 different incisions used for atrial-septal defect closure.

BACKGROUND Surgical closure of atrial-septal defects is now associated with low morbidity and mortality rates. We assessed surgical, cosmetic, and psychological results of 3 different surgical approaches to atrial-septal defect repair. METHODS Study participants were 82 patients who underwent surgery for atrial-septal defect. Mean age was 21 +/- 8 years, and the female:male ratio was 23:59. Patients were divided into 3 groups according to the incision used; group 1 (n = 26), partial lower sternotomy; group 2 (n = 34), right anterolateral thoracotomy via a submammary incision, and group 3 (n = 22), conventional median sternotomy. RESULTS There was no operative or late mortality. No significant differences between groups were associated with the surgical technique used. Direct closure was the procedure of choice performed in 53 patients (64.6%). In the remaining patients the repair was performed with a pericardial patch (29 patients, 35.4%). One patient in group 1 required conversion to median sternotomy because transoesophageal echocardiography performed at the operating theater revealed a partial anomalous pulmonary venous connection of right pulmonary veins to the inferior vena cava. This patient was excluded from the study group. All patients were symptom free postoperatively, and control echocardiography revealed a trivial shunt in only 1 patient, with a Qp:Qs ratio of 1.3. Rhythm abnormalities, including atrioventricular block, atrial fibrillation, and flutter, were observed in 7 patients but were found to be unrelated to the surgical incision (P = .3). Cardiopulmonary bypass, cross-clamp, and operative times were longer with minimally invasive approaches; but these differences were not statistically significant. Intensive care unit and hospital stay periods were significantly shorter in groups 1 and 2. During the postoperative follow-up period, patients in groups 1 and 2 showed superior results in satisfaction with their cosmetic outcomes. CONCLUSIONS With the development of minimally invasive techniques that yield surgical results comparable to those of standard techniques, surgeons have changed their focus from survival to cosmetic and psychological outcomes, especially in the repair of simple cardiac defects. Operations performed via limited skin incisions are surgically safe and provide superior cosmetic and psychological results.

The surgical treatment of abdominal aortic aneurysms in patients with light to moderate renal dysfunction.

Abstract Objective : The incremental surgical risk caused by mild or moderate renal dysfunction in patients undergoing surgery for an abdominal aortic aneurysm is not well defined. The aim of this study is to analyze the prognostic significance of mild or moderate renal dysfunction in 79 patients who have undergone repair of an infrarenal abdominal aortic aneurysm at our institution. Methods : The postoperative results of 35 non-dialysis-dependent patients (Group I) with renal dysfunction were included and compared with a group of 44 patients (Group II) with similar characteristics of age, gender and pre-operative risk factors. All operations were performed through a standard transperitoneal median laparotomy. Results : The mean operation and aortic cross-clamp times did not differ significantly between the two groups (234 ± 15 min vs. 189 ± 17min; p = 0.25 and 57 ± 12 min. vs. 52 ±9 min.; p = 0.52). Early operative mortality was 5.71% in patients with renal dysfunction and did not differ significantly when compared with the other group of patients 4.5%; p = 0.083). Blood requirement was higher (p < 0.01) and the hospital stay was longer (p < 0.001) in group I. There were 18 patients in group I (51.4%) and three patients in group II (6.8%) in whom the pre-operative serum creatinine level increased above 2.5 mg/dl during the postoperative period. The postoperative increase of creatinine level differed significantly in patients with pre-operative renal dysfunction (p < 0.001). There were nine patients (25.7%) in group I and four patients (9.1%) in group II who required mechanical ventilation for more than 24 hours (p = 0.025). There was no significant difference between the two groups in terms of cardiac morbidity p = 0.234). Conclusion : Patients with even a mild or moderate degree of renal dysfunction require close monitoring and prolonged hospital care during the postoperative period. Although satisfactory early surgical outcomes may be expected in this particular group of patients, pulmonary and renal morbidity rates are higher than in patients with normal renal function.

Single-stage unifocalization and correction with median sternotomy in complex pulmonary atresia ☆

OBJECTIVE This study assessed the surgical and post-operative outcome of single-stage complete unifocalization and repair procedure in patients with complex pulmonary atresia. METHODS From 1999 to 2001, we performed complete unifocalization and correction in 10 patients with complex pulmonary atresia. Their ages ranged from 10 months to 17 years. All patients were evaluated with pulmonary angiography and divided into two groups according to the development of native pulmonary arteries. Group I patients had hypoplastic pulmonary arteries and MAPCAs and Group II patients had only MAPCAs without native pulmonary arteries. With median sternotomy, all MAPCAs were prepared and anastomozed to native pulmonary arteries in group I patients or on a pericardial roll in group II patients without using cardiopulmonary bypass. Right ventricle to pulmonary arterial continuity was established with a valved conduit under CPB. VSD was closed in two patients. RESULTS Eight patients had complete repair without VSD closure. They were followed periodically with pulmonary angiography. Two patients developed congestive heart failure. One of them was reoperated and VSD was closed. The other patient died because of untractable congestive heart failure. The decision for VSD closure was made in two patients due to suitable pulmonary arterial vascular tree. However, one of them had to be reoperated and VSD patch was removed. This patient died because of sepsis on the postoperative 26th day. We are following the rest of the patients with echocardiography and pulmonary angiography. CONCLUSION Single stage complete unifocalization and repair should be the treatment of choice in patients with complex pulmonary atresia. This procedure provides a significant development in neopulmonary arterial system. However, the accurate criterias for VSD closure are still controversial. After the operation, these patients had to be followed closely with echocardiography and pulmonary angiography because of the absolute risk of congestive heart failure in patients with VSD left open.