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Acute Mesenteric Ischemia after Cardiac Surgery: An Analysis of 52 Patients

Objective. Acute mesenteric ischemia (AMI) is a rare but serious complication after cardiac surgery. The aim of this retrospective study was to evaluate the incidence, outcome, and perioperative risk factors of AMI in the patients undergoing elective cardiac surgery. Methods. From January 2005 to May 2013, all patients who underwent cardiac surgery were screened for participation, and patients with registered gastrointestinal complications were retrospectively reviewed. Univariate analyses were performed. Results. The study included 6013 patients, of which 52 (0.86%) patients suffered from AMI, 35 (67%) of whom died. The control group (150 patients) was randomly chosen from among cases undergoing cardiopulmonary bypass (CPB). Preoperative parameters including age (P = 0.03), renal insufficiency (P = 0.004), peripheral vascular disease (P = 0.04), preoperative inotropic support (P < 0.001), poor left ventricular ejection fraction (P = 0.002), cardiogenic shock (P = 0.003), and preoperative intra-aortic balloon pump (IABP) support (P = 0.05) revealed significantly higher levels in the AMI group. Among intra- and postoperative parameters, CPB time (P < 0.001), dialysis (P = 0.04), inotropic support (P = 0.007), prolonged ventilator time (P < 0.001), and IABP support (P = 0.007) appeared significantly higher in the AMI group than the control group. Conclusions. Prompt diagnosis and early treatment should be initiated as early as possible in any patient suspected of AMI, leading to dramatic reduction in the mortality rate.

Intracoronary Shunt Versus Bulldog Clamp in Off-Pump Bypass Surgery. Endothelial Trauma: Shunt Versus Clamp

BACKGROUND During off-pump coronary bypass grafting, local vascular control of the target vessel and a bloodless field are crucial. The aim of this study is to asses the histopathological outcomes of intracoronary shunts and bulldog clamping on the beating heart in a canine model. METHODS Twelve healthy adult mongrel dogs weighing between 15 to 25 kg were included in the study. Following left thoracotomy, proximal left anterior descending artery segment 1 cm to distal of diagonal branch was marked. Arteriotomy at this site was performed and a shunt was inserted for 10 min in the shunt group. The bulldog clamp was applied 3 cm distal to the mark for 10 min after heparinization in the bulldog group. Thirty days after the procedure, the specimens of left anterior descending artery from both regions were collected and were examined. Vascular damage, presence of intimal hyperplasia, and denudation were noted. RESULTS Only intimal denudation was found significantly higher in the shunt group (P < 0.05). In this group, only one case had grade 0 endothelial damage. In the bulldog group, all cases had endothelial damage of various grades. CONCLUSION The proven advantages of temporary intracoronary shunts are well-known, e.g., preserving the ventricular functions. Despite these advantages, our study revealed an ultimate bad result for an off-pump coronary by pass patient: intimal denudation. We conclude that further studies with a larger number of subjects are needed to decide whether routine shunt insertion into coronary arteries during off-pump coronary bypass surgery is appropriate or not.

Deep sternal wound infection after coronary artery bypass surgery: management and risk factor analysis for mortality.

BACKGROUND Deep sternal wound infection is a life-threatening complication after cardiac surgery. The aim of this study was to investigate the factors leading to mortality, and to explore wound management techniques on deep sternal wound infection after coronary artery bypass surgery. METHODS Between 2008 and 2013, 58 patients with deep sternal wound infection were analyzed. Risk factors for mortality and morbidity including age, gender, body mass index, smoking status, chronic renal failure, hypertension, diabetes, and treatment choice were investigated. RESULTS In this study, 19 patients (32.7%) were treated by primary surgical closure (PSC), and 39 patients (67.3%) were treated by delayed surgical closure following a vacuum-assisted closure system (VAC). Preoperative patient characteristics were similar between the groups. Fourteen patients (24.1%) died in the postoperative first month. The mortality rate and mean duration of hospitalization in the PSC group was higher than in the VAC group (P = .026, P = .034). Significant risk factors for mortality were additional operation, diabetes mellitus, and a high level of EuroSCORE. CONCLUSIONS Delayed surgical closure following VAC therapy may be associated with shorter hospitalization and lower mortality in patients with deep sternal wound infection. Additional operation, diabetes mellitus, and a high level of EuroSCORE were associated with mortality.

Effects of hyperbaric oxygen therapy combined with platelet-rich plasma on diabetic wounds: an experimental rat model

Introduction Hyperbaric oxygen and platelet-rich plasma are used in the treatment of diabetic wounds. The aim of this study is to evaluate the effects of hyperbaric oxygen therapy and autologous platelet concentrates in healing diabetic wounds. Material and methods Thirty-six female Wistar albino rats were used in this study. Diabetes mellitus was induced chemically with an intraperitoneal injection of streptozotocin. The rats were divided into a control group, a hyperbaric oxygen group, a platelet-rich plasma group, and a combined therapy group. Platelet-rich plasma was applied just after the creation of the wound; hyperbaric oxygen treatment was carried out daily over 7 days. Wound healing was evaluated according to four parameters: ulcerations, epidermal thickness, density of dermal collagen fibers, and proliferation of dermal blood vessels. Results The number of active ulcers in the combined therapy group was fewer than in the control group (p = 0.039), and the wound area was greatest in controls (p < 0.001). The epidermal thickness in platelet-rich plasma and combined therapy groups was non-significantly greater than in the control group (p = 0.097 and p = 0.074, respectively). The amount of fibrous collagen in these two groups was greater than in the control group (p = 0.002). Conclusions Combined hyperbaric oxygen and platelet-rich plasma therapy was found to be successful in diabetic wound healing. The combination therapy had no additive effect in terms of angiogenesis and the development of new collagen fibers.

Unilayer Closure of Saphenous Vein Incision Lines is Better than Bilayer Closure

Objective: To examine early results in patients with incision lines closed only along the skin and subcutaneous tissue after removal of the great saphenous vein during coronary artery bypass surgery. Materials and Methods: We enrolled 82 patients who underwent elective operations in our clinic between December 2008 and April 2009. The patients had similar demographic characteristics, and the method of incision closure was chosen randomly. Three patients were excluded due to in-hospital mortality. The saphenous incision lines were closed using continuous skin sutures in 41 patients (Group 1) or using continuous subcutaneous sutures followed by continuous skin sutures in 38 patients (Group 2). Patients were followed every day that they were in the hospital, in the first week after being discharged, and at the end of the second month after discharge. The incision lines were evaluated for hematomas, infection, edema, pain and numbness. Results: During the follow-up performed in-hospital and in the first week after discharge, infection, edema and numbness were observed significantly more often in Group 2 than in Group 1. Hematoma was observed more often in Group 1, and pain was observed more often in Group 2, but neither of these findings reached statistical significance. During the follow-up at the end of the second month after discharge, infection, edema, and numbness were observed significantly more frequently in Group 2. Conclusion: In patients undergoing saphenous removal using standard procedures, it is sufficient to close the incision line using only skin sutures.

Posttraumatic true aneurysm of the axillary artery following blunt trauma.

The majority of the axillary artery aneurysm cases arise as pseudoaneurysms secondary to blunt or iatrogenic trauma. Isolated traumatic true axillary artery aneurysm is a relatively unusual disorder and generally occurs with repetitive blunt trauma. A 22-year-old female patient with distal axillary artery true aneurysm due to simple blunt axillothoracic trauma is presented. The aneurysm was excised with subpectoral-axillary approach and saphenous vein graft interposition was applied. Long-term follow-up with the patient was uneventful.

eComment. Extended utilization of axillary cannulation as arterial access for cardiopulmonary bypass

In cardiovascular practice today, the axillary artery is one of the best alternative cannulation sites in acute type A aortic dissection [1]. It provides potential benefits such as antegrade perfusion of the aorta, low risk of false lumen perfusion in aortic dissection, and the possibility of antegrade cerebral perfusion during aortic arch repair. Indications of axillary cannulation also includes porcelain aorta, ascending aorta and aortic arch aneurysm, coronary artery disease associated with severely atherosclerotic ascending aorta, extracorporeal membrane oxygenation support, and complex redo cardiac surgery such as aortic regurgitation after previous ascending aortic replacement and pseudo-aneurysm after Bentall operation. We read with great interest the article by Fong and associates [2], regarding liberal use of axillary artery cannulation for cardiopulmonary bypass in aortic and complex cardiac surgical patients. We mostly agree with their considerations. However, we believe that some aspects of the article require further comment. Direct or graft-interposed axillary cannulation still remains a controversial issue among the cardiovascular surgeons. We routinely prefer direct right axillary cannulation in acute type A aortic dissections in our institute [3]. In our practice, there were no major complications related to this cannulation technique. In our opinion, direct axillary cannulation is not more traumatic, is less time-consuming, and less haemorrhagic during the operation than the graft interposition. Axillary cannulation is not always free from risk. Complications related to axillary cannulation are becoming associated with increased use of this technique [4]. These include ipsilateral brachial plexus injury resulting in hand weakness and numbness, axillary artery thrombosis, lymphocele requiring aspiration, vascular compromise, compartment syndrome involving the forearm, postoperative bleeding or local wound infection. Acute intraoperative aortic dissection due to the arterial cannulation into the axillary artery is a rare and devastating complication [5]. It is believed to be due to an intimal flap occurring during cannula insertion. As a strategy to prevent these complications, the arterial cannula should not be advanced too much during the right axillary cannulation. Forced cannulation should also be absolutely avoided. It may cause arterial injury or obstruct the right carotid artery. In our experience, a 20F or 22F flexible cannula was gently advanced 3-4 cm into the axillary artery. In strategic planning for arterial cannulation, transoesophageal echocardiography (TEE) guidance is useful to ensure correct placement of the cannula. An angiograhic, TEE or ultrasound examination plays an important role in preoperative evaluation including aortic branch vessels Axillary cannulation is an attractive and useful approach with an extended utilization, and may be safely used in aortic surgery and complex cardiac procedures including redo surgery. Conflict of interest: none declared.

Delayed Presentation of a Giant Ascending Aortic Aneurysm following Aortic Valve Replacement

Giant ascending aortic aneurysm formation following aortic valve replacement is rare. A 28-year-old man who underwent aortic valve replacement with a prosthetic valve for aortic regurgitation secondary to congenital bicuspid aortic valve about 10 years ago was diagnosed with a giant ascending aortic aneurysm about 16 cm in diameter in follow-up. The aneurysm was resected leaving the functional old mechanical prosthesis in place and implanted a 34-mm Hemashield woven graft, associated with the left and right coronary artery button implantation. Histological findings of the aortic aneurysm wall showed cystic medial necrosis. The postoperative course was uneventful and postoperative examination demonstrated good surgical results.

Left atrial myxoma combined with coronary artery disease in an elderly patient

Cardiac myxoma associated with coronary artery disease is a rare pathology in an elderly patient. Herein we present an 81-year-old woman undergoing simultaneous surgical treatment for left atrial myxoma combined with coronary artery disease. The postoperative course of the patient was uneventful. The initial removal of mass should be performed to prevent systemic embolization of tumor fragments.

The Comparison of the Effects of Nebivolol and Metoprolol on Erectile Dysfunction in the Cases with Coronary Artery Bypass Surgery

PURPOSE Beta-blocker use is common in the cases with coronary artery bypass surgery. According to the literature, beta-blockers have positive effects but may cause erectile dysfunction (ED). The most commonly used beta-blockers in ischemic cardiac disease are nebivolol and metoprolol. In our clinic, we aimed to compare the effects of nebivolol and metoprolol succinate on ED in the sexually active cases with coronary artery bypass surgery. METHODS In our clinic, a total of 119 patients with coronary artery bypass surgery were included in the study. International Index of Erectile Function (IIEF-5) Test was used to evaluate whether the patients had ED and to grade the cases. RESULTS No significant difference was found in terms of anti-ischemic efficacy between metoprolol succinate and nebivolol in the postoperative period; however, the incidence of any grade ED was %85.96 in Group 1, %83.87 in Group 2. This difference was considered as statistically significant (p = 0.036). CONCLUSION Beta-blocker use increases the risk of ED in cases with ischemic cardiac disease. We suggest that the complaints of ED could be less frequent with nebivolol use in sexually active cases with ischemic cardiac disease.