Hakki Kazaz

Intrapericardial fibrynolytic therapy in purulent pericarditis

OBJECTIVE Purulent pericarditis is a rare disease that is being conventionally managed with intravenous antibiotics and pericardial drainage. In our study, we used intrapericardial fibrinolytic treatment together with pericardiocentesis and antibiotic therapy. We evaluated the role of intrapericardial fibrinolytic treatment in nine purulent pericarditis patients. METHODS Six children and three adult patients with purulent pericarditis, aged between 5 and 50 years, were treated with intrapericardial fibrinolysis by streptokinase. Intrapericardial drainage catheter was placed into the subxyphoidal localization under local anaesthesia and echocardiography guidance, streptokinase was infused into the pericardial sac as the fibrinolytic agent. RESULTS Repeat echocardiograms showed no reaccumulation of pericardial effusions, pericardial thickening or constrictions. No patients had systemic bleeding, arrhythmias, or hypotension. There was one death which was due to sepsis and congestive heart failure. CONCLUSION We believe that early pericardial drainage and intrapericardial fibrinolysis appears to be safe and effective in the treatment of purulent pericarditis.

Readmission and mortality in patients undergoing off-pump coronary artery bypass surgery with fast-track recovery protocol.

The development of less invasive methods for myocardial revascularization such as “off-pump” cardiac surgery, and new methods of anesthesia and postoperative care protocols such as “fast-track recovery” (FTRC), have contributed to a significant reduction in postoperative intensive care unit (ICU) and hospital length of stay after cardiac surgical procedures. The objectives of this study were to identify perioperative risk factors of prolonged hospital stay, hospital mortality, and readmission rates in off-pump coronary artery bypass surgery (CABG) patients undergoing the FTRC protocol. Eighty consecutive patients undergoing off-pump coronary artery bypass surgery with FTRC protocol were included in the study. For the first purpose of this protocol, early extubation is defined as removal of the endotracheal tube within 6 h of arrival at the surgical ICU. The second purpose was to obtain a minimal length of stay in the ICU (<24 h) and hospital discharge within 5 days. We analyzed the influence of the preoperative, intraoperative, and postoperative variables on prolonged hospital stay, hospital mortality, and hospital readmission. Three patients died during hospitalization, giving a hospital mortality rate of 3.75%. The causes of hospital death were massive stroke and sepsis. Using multivariate logistic regression analysis, hypertension (P = 0.0185), postoperative stroke (P = 0.0001), and sternal infection (P = 0.0007) were identified as independent predictors of hospital mortality. Mean hospital length of stay was 4.23 ± 0.75 days. Univariate and multivariate logistic regression analysis revealed that postoperative blood use (P = 0.0095) was the major independent predictor of prolonged hospital stay. During the 30-day observation period, seven patients were readmitted. One of these patients died on postoperative day 45 from mediastinitis and sepsis. Multivariate logistic regression analysis identified age (P = 0.0033) and hypertension (P = 0.045) as independent predictors of hospital readmission. FTRC protocols can be performed safely in patients with off-pump CABG, and the mortality and readmission rates following this protocol were found to be within acceptable ranges.

Is Chlamydia pneumoniae a risk factor for peripheral atherosclerosis

Seroepidemiological studies have shown a relationship between Chlamydia pneumoniae and coronary atherosclerosis. It is not clear whether Chlamydia pneumoniae is also a risk factor for peripheral atherosclerosis. Chlamydia pneumoniae antibodies were measured by a microimmunofluorescence method in 75 patients who underwent surgery for peripheral atherosclerosis, and the seroprevalence was compared with that in the normal population. Chlamydia pneumoniae immunoglobulin-G seroprevalence was 80% in the study group vs. 40% in controls. More foam cells were noted on light microscopy in atherosclerotic plaques from the infected patients. The 60 infected patients were divided into: group A (n = 35) given both anti-chlamydial and antiplatelet agents for 1 year; and group B (n = 25) given antiplatelet therapy only. The groups were compared on the basis of clinical findings, ankle-brachial index, and antibody titers. Decreasing Chlamydia pneumoniae immunoglobulin-G seroprevalence in group A correlated significantly with increasing ankle-brachial index and improvement in clinical findings. It was concluded that Chlamydia pneumoniae may be a risk factor for peripheral atherosclerosis.

Comparison of the effects of lornoxicam versus diclofenac in pain management after cardiac surgery : A single-blind, randomized, active-controlled study

BACKGROUND Inadequate pain management after cardiac surgery may result 10 in increased morbidity and length of hospital stay. Although opioids are the mainstay of postoperative analgesia, nonsteroidal anti-inflammatory drugs (NSAIDs) may be used instead to avoid the adverse effects (AEs) associated with opioids. Lornoxicam is a newly developed NSAID, the use of which is increasing. However, lornoxicam has not been studied for use in pain management after cardiac surgery. OBJECTIVE The objective of this study was to compare the efficacy and tolerability 10 of lornoxicam and diclofenac sodium, an NSAID well established for use in pain management after major surgery, in pain management after coronary artery bypass grafting (CABG). METHODS This single-blind, randomized, active-controlled study was conducted 10 at the Gaziantep University Hospital, Gaziantep, Turkey. Adult patients scheduled to undergo valve or CABG surgery for the first time were included. Patients were premedicated with diazepam 10 mg PO at 10 PM on the evening before surgery. General anesthesia was induced using fentanyl, midazolam, and propofol, and maintained using fentanyl and isoflurane in pure oxygen. After extubation and when they stated that they felt pain, patients were randomly assigned to 1 of 2 treatment groups: lornoxicam 8 mg IM q8h or diclofenac 75 mg IM q12h, for 48 hours. Meperidine 1 mg/kg IM was given for additional analgesia when needed (rescue medication). Pain relief was assessed using an I1-point visual analog scale (0 = no pain to 10 = worst pain imaginable) immediately before the first injection (baseline), and at 15 and 30 minutes and 1, 2, 3, 4, 6, 12, 18, 24, and 48 hours after the first injection. Sedation was assessed using a 5-point scale (0 = awake and alert to 4 = deep sedation) at the same time points. Tolerability was assessed by monitoring of AEs using patient interview and laboratory analyses. RESULTS Forty patients were enrolled in the study (30 men, 10 women; 10 mean [SD] age, 54.4 [11.1 ] years; 20 patients per treatment group). The demographic and clinical characteristics and mean baseline pain relief scores were statistically similar between the 2 treatment groups. The mean pain relief scores at 15 and 30 minutes were statistically similar to baseline values in the 2 treatment groups. However, the mean pain relief scores at ≥1 hour after the first injection were significantly lower compared with baseline values (both groups, P < 0.05 at time points ≥1 hour). No significant between-group differences in mean pain relief scores were found at any time point. The overall mean pain relief scores were statistically similar between the 2 treatment groups. The mean sedation scores were significantly higher at 30 minutes, 1 hour, and 2 hours after the first injection in the diclofenac group compared with the lornoxicam group (all, P < 0.05). No AEs were observed. The need for rescue medication was statistically similar between the 2 treatment groups (lornoxicam, 2 patients; diclofenac, 3 patients). CONCLUSIONS In this study of adult patients who underwent CABG, the efficacy 10 of lornoxicam and diclofenac were similar in postoperative pain management. Both study drugs were well tolerated.

Symptomatic coronary-subclavian steal syndrome due to total occlusion of proximal left subclavian artery

Symptomatic coronary-subclavian steal occurs infrequently. We report a case involving angina pectoris in a patient with a patent left internal thoracic artery graft on the left anterior descending coronary artery and total occlusion of the proximal left subclavian artery.

Randomized comparison of vasodilator effects of iloprost versus diltiazem on flow and pathologic changes in radial arteries: mid-term angiographic control study of the comparison of vasodilators on radial artery vasospasm.

BACKGROUND The increasing prevalence of routine radial artery (RA) use in coronary artery bypass grafting (CABG) has rendered the pharmacologic prevention of spasm of this artery a critical consideration in the early postoperative period and in the long-term outcome. In this study, we compared the effects of iloprost and diltiazem on vasospasm. METHODS Seventy patients who underwent CABG with the RA were randomized into 2 groups, and the vasodilator effects of iloprost and diltiazem were studied prospectively. RA flow was measured with Doppler ultrasonography. Following harvesting, a 5-mm piece was removed from the RA distally for pathologic examination. In group B, diltiazem was infused before removing the RA, whereas in group A, iloprost infusion was initiated 5 days before surgery. At the end of a 2-year follow-up, each patient underwent coronary angiography. RESULTS Doppler flow measurements made during harvesting revealed a statistically significant reduction in flow, and a pathologic examination of the RAs revealed significant luminal narrowing in group B. A 2-year angiographic follow-up revealed all of the RA grafts in group A to be patent. CONCLUSIONS Our evaluation of the results revealed the superior efficacy of iloprost over diltiazem in preventing RA spasm in the early period, and the 2-year angiographic findings showed that the use of iloprost produced superior mid-term patency.

Deep pericardial suture vs apical suction for off-pump bypass grafting.

Hemodynamic changes during heart luxation and stabilization are major problems in off-pump coronary artery bypass surgery. The hemodynamic effects of an apical suction device were compared with those of the classic posterior pericardial suture in 45 patients with multivessel coronary disease undergoing off-pump coronary artery bypass. Mean age was 63.78 ± 8.11 years; 31 patients were male and 14 were female. Transesophageal Doppler echocardiography was used for hemodynamic monitoring. All hemodynamic parameters were significantly better when the apical suction device was used to position the heart for anastomoses on the posterior descending and circumflex arteries.

Congenital systemic arteriovenous fistula between the distal thoracic aorta and hemiazygos vein in a child

Congenital thoracic arteriovenous fistulas have been rarely described [1, 2, 3, 4, 5,6]. Therefore, a congenital systemic arteriovenous fistula arising from the thoracic aorta and draining into azygos or hemiazygos vein is extremely [1, 3, 4,6]. Such lesions are usually accompanied by a continuous murmur. The extent of clinical manifestations is related to the size, duration, and the precise location of the collaterals. Although physical diagnosis may be easy with careful examination if lesions are located superficially, angiography is important in delineating the anatomy, and to decide on the appropriate management of the patient. In this report, a rare case of congenital systemic arteriovenous fistula between the descending aorta and hemiazygos vein is presented. A 15-month-old girl was referred to our paediatric cardiology unit for cardiac evaluation following incidental detection of an intensive continuous murmur in the left paraspinal region. There was no family history of congenital heart disease. Her height was 80 cm (75th– 90th percentile), and weight 9 kg (10th–25th percentile). The physical examination was normal except for a murmur. The pulse rate was 120/min and blood pressure 90/50 mm Hg with normal heart sounds. A chest X-ray film showed a normal heart size and pulmonary vascularity. Normal function and structure were detected by transthoracic echocardiography. A contrast-enhanced CT scan with 2.5 mm slice thickness and increments of the thorax demonstrated a tortuous vascular malformation coursing from the descending thoracic aorta to the hemiazygos vein at the left paravertebral localisation in the posterior mediastinum (Fig. 1). Angiography of the distal descending thoracic aorta revealed a thoracic arteriovenous fistula. Selective angiography of the fistula was performed and we observed that the fistula was draining into the hemiazygos vein. The fistula coursed posteriorly into the hemiazygos system before draining into the azygos vein and vena cava superior (Fig. 2). The calculated ratio of the pulmonary blood flow to systemic flow was 1.2. Since the patient was asymptomatic, no therapy was advised. Bacterial endocarditis prophylaxis was recommended. Thereafter, she was discharged and followed up for a year and there was no additional symptom except continuous murmur. Arteriovenous fistula is characterised by abnormal shunting of blood between the arterial and venous systems without the presence of a normal intervening capillary bed. Since the capillary bed represents the source of resistance to blood flow in the circulatory system, arteriovenous collaterals are low resistance, high flow lesions [2]. A congenital systemic arteriovenous fistula arising from the thoracic aorta and draining into the azygos or hemiazygos vein is extremely rare [1, 3, 4,6]. To our knowledge, our case is the second in the literature [1]. Soler et al. [6] postulated that this particular type of malformation could be attributed to abnormal fistulous communications between embryological arterial and venous channels that were originally normal. The clinical features of arteriovenous collaterals depend on their location and involved blood vessels. Although diagnostic investigation may be necessary, clinical examination is essential. A physician can hear a distinctive continuous murmur in the affected region using a stethoscope. If the fistula is large enough, heart failure may develop. Therefore, careful clinical followup is essential. Since the degree of left to right shunt was low in our patient, fistula closure was not indicated. In fact, Saito et al. [4] reported that regression of an O. Baspinar (&) Æ H. Kazaz Department of Paediatric Cardiology and Cardiovascular Surgery, Gaziantep Üniversitesi Tip Fakültesi Pediatri ABD, 27310 Gaziantep, Turkey E-mail: osmanbaspinar@hotmail.com Tel.: +90-342-3606060 Fax: +90-342-3603928

Retrospective analysis of surgically treated infective endocarditis cases.

BACKGROUND Prosthetic valve endocarditis (PVE) and native valve endocarditis (NVE) both cause high rates of morbidity and mortality and are significant health problems in our community. Optimal timing of the surgical intervention depends on the hemodynamic stability of the patient. In the present study, we retrospectively evaluated the clinical status, bacteriology, morbidity, and mortality parameters of infective endocarditis cases that were treated surgically. METHODS Thirty patients (20 male and 10 female) who underwent cardiac valve surgery between April 2001 and December 2006 were included in the study. The mean (SD) age of the patients was 36.5 +/- 5.42 years. Thirty-five surgical operations were conducted on 30 patients. We evaluated the patient demographic, etiologic, and surgical data retrospectively with respect to mortality and morbidity. RESULTS The mean time to develop PVE was 13 months. We recorded a mortality rate of 16.6% (2 deaths in NVE operations and 3 deaths in PVE operations). Repeat surgeries were performed in 2 aortic valve cases and 3 mitral valve cases in which paravalvular leakage was noticed in the prosthetic valves. CONCLUSION Despite significant medical and surgical advances, both NVE and PVE still continue to be causes of high mortality and morbidity rates in cardiac surgery.

Postcardiotomy Extracorporeal Life Support

The need for postcardiotomy mechanical support is uncommon and likely to decline. A mixture of options is necessary to meet the diverse indications for cardiac support in a comprehensive heart failure program. Between January 1997 and December 2000, 29 adult, neonate, and infant cardiac surgical patients were supported on an extracorporeal life support system. Indications for cardiac assist included post-cardiotomy low cardiac output syndrome, and hyperacute rejection after cardiac transplantation. Data for analysis were collected prospectively. Survival on the life support system was 20/29 (69%) and 12 patients (41%) survived to discharge. The mean time to starting extracorporeal life support was longer in survivors than non-survivors. The extracorporeal life support system provides effective cardiopulmonary and end-organ support.