Hakan Bingöl

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 Treatment of Coronary Artery Fistulas: 15 Years' Experience

We report our experience of surgical treatment of coronary artery fistula and focus on the electrocardiographic changes that may be seen postoperatively. Between 1988 and 2003, cardiac operations were carried out on 9,487 patients, of whom 21 had a coronary artery fistula. The mean age of these 21 patients was 36.8 ± 4.9 years. The fistula originated from the right coronary artery in 9 cases and from the left side in 12. The fistulous connection was to the right ventricle in 5 patients, to the right atrium in 6, to the pulmonary artery in 8, and to the coronary sinus in 2. There was no operative mortality. Two patients (10%) had nonspecific electrocardiographic changes during the postoperative period. Repeat coronary angiography revealed normal coronary anatomy in both, and their electrocardiograms normalized within 2 months. Patients suspected to have myocardial ischemia related to the surgical procedure, with ST segment depression or T wave abnormalities on the electrocardiogram, should undergo repeat angiography to eliminate the possibility of coronary artery damage.

Prophylactic dialysis in elderly patients undergoing coronary bypass surgery.

Abstract:  Renal dysfunction is associated with markedly increased risk for both mortality and morbidity in patients undergoing coronary artery bypass surgery (CABG), especially in elderly patients. In the current study, we aimed to determine the impact of prophylactic preoperative hemodialysis on operative outcome in patients with mild renal dysfunction. Between March 2002 and May 2005 a total of 64 patients, all of whom were more than 70 years of age and with preoperative creatinine levels greater than 2 mg/dL, underwent primary elective on pump coronary artery bypass surgery. The mean age was 76.3 ± 6.4 (range 70–83). The patients were prospectively allocated into two groups. Group A was the dialysis group (31 patients) and preoperative prophylactic hemodialysis was carried out in all patients. Group B (33 patients) was taken as a control group without preoperative hemodialysis. During the present study, 10 patients died (15.6%) in the hospital. In the postoperative period mean levels of creatinine were found to be decreased in dialysis group. (2.3 ± 0.8 mg/dL vs. 3.4 ± 0.2 mg/, P = 0.037). The incidence of overall morbidity (such as acute renal failure, need of postoperative dialysis, low cardiac output and multiple organ failure) were also found to be decreased in dialysis group. We conclude from the present study that preoperative renal dysfunction and advanced age increase the risk of mortality and morbidity after on‐pump coronary artery bypass surgery. We believe that perioperative prophylactic hemodialysis is an easy and effective method and it decreases both operative mortality and morbidity in elderly patients with renal dysfunction. 

Pre-emptive stellate ganglion block increases the patency of radial artery grafts in coronary artery bypass surgery.

Background:  We evaluated the role of pre‐emptive stellate ganglion block (SGB) in preventing radial artery spasm and increasing radial artery graft patency in patients undergoing off‐pump coronary artery bypass surgery.

Left Ventricular Endoaneurysmorrhaphy: Effect on Left Ventricular Size, Shape and Function

Left ventricular (LV) endoaneurysmorrhaphy is a relatively new surgical procedure with excellent results. Forty-five patients underwent surgical repair of LV aneurysm with LV endoaneurysmorrhaphy from 1991 to 1995. The main indication for operation was angina pectoris (71%). Concomitant myocardial revascularization was performed in 97% of the patients. The operative mortality rate was 2.2%. Pharmacologic inotropic support was required in 31% and mechanical support in 15%. Mean echocardiographic ejection fraction improved from 29.6% preoperatively to 48.3% postoperatively (p <0.001). LV end-diastolic volumes were 195 +/- 63 and 118 +/- 44 ml before and after surgery (p <0.01). Intraoperative transesophageal echocardiography revealed normal or near-normal LV shape in all cases. The mean follow-up was 34.0 +/- 9.2 months (16-50 months) and 1 patient died 9 months postoperatively. We conclude that endoaneurysmorrhaphy improves LV geometry and function in patients with LV aneurysms and can be performed with low surgical risk even in patients with large aneurysms and severely depressed LV function. ........

A concealed penetrating cardiac injury.

Abstract  We present the case of a 29‐year‐old man who had been the victim of a stab wound. The cardiac wound was localized in the left ventricular apex and the posterior side of the left ventricle. When he was brought to the emergency department, he had no significant symptoms related to the cardiac wound regardless of ECG changes in the V2‐V4 precordial derivation. The aim of this case report is to demonstrate the importance of an accurate preoperative diagnosis and urgent surgical intervention to ensure a good outcome in this type of rare case.

Left anterior descending artery arising as a terminal extension of posterior descending artery (a rare coronary artery anomaly).

Several types of left anterior descending artery anomalies have been detected. In these anomalies, left anterior descending artery usually originates from the right coronary artery or right sinus of Valsalva. A case of left anterior descending artery arising as a terminal extension of posterior descending artery presented. This anomaly seems rather rare.

Late onset LIMA first branch steal syndrome after coronary artery bypass surgery.

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Discrete Subaortic Stenosis: Assessing Adequacy of Myectomy by Transesophageal Echocardiography

Abstract Background; Membranectomy and myectomy are standard therapy for discrete subaortic stenosis (DS) and are associated with low rates of endocarditis, recurrence, and aortic insufficiency. Extensive myectomy increases risk of complications such as conduction tissue damage and iatrogenic ventricular septal defect (VSD). Materials and Methods: Forty‐five adult patients with DS underwent operations in Gulhane Military Medical Academy. Ex‐ertional dyspnea was the principal symptom in 29 (64.496) patients. Transesophageal echocardiography (TEE) was performed routinely in all patients to assess the length and depth of needed myectomy during the perioperative period. Aortic insufficiency (AI) was also noted preoperatively in 31 (68·9%) and a history of aortic valve endocarditis was present in 4 (8·9%) patients. Results: Myectomy was performed according to TEE measurements. An average of 10 mm in width, 10 mm in depth, and 2·3 mm in length of septal tissue was resected. The mean left ventricle‐aorta peak systolic gradient decreased from 70·2 ± 9·7 to 17·2 ± 2·7 mmHg (p<0·001). Aortic valve repair was performed in 8 (7·8%) patients and aortic valve replacement in 11 (24·4%) patients at the initial operation. Iatrogenic VSD did not occur in any of the patients. Average postoperative left ventricular outflow tract diameter was 21 ± 1·5 mm. Temporary complete heart block occurred in three patients. There was an early residual gradient (36 ± 8 mmHg) resulting from temporary hypercontraction that decreased (18 ± 5 mmHg) in the first postoperative day. Conclusions: Myectomy under perioperative TEE measurement is safe and effective in the treatment of DS. TEE‐guided myectomy reduces complications such as complete heart block and iatrogenic VSD.

Novel variant of dual left anterior descending artery arising from single right coronary artery anomaly presenting with angina inversa

A 55-year-old female without a history of coronary artery disease, hypertensive for the past 17 years, was admitted with resting chest pain. Electrocardiography revealed a negative T-wave in anterior chest leads. Coronary angiography visualised anomalous coronary anatomy, with a common origin of the right coronary artery and the left main coronary artery in the right sinus of Valsalva serving as a common coronary trunk. It should be emphasised that T-wave abnormalities and chest angina may be related to this congenital coronary anomaly.