Halil Ibrahim Ucar

Preoperative Fibrinogen Levels as a Predictor of Postoperative Bleeding after Open Heart Surgery

BACKGROUND Open heart surgery still involving major bleeding continues to be a major challenge after cardiac surgery and is also a significant cause of morbidity and mortality. Most hemostatic factors are intercorrelated with postoperative bleeding, and fibrinogen seems the most fundamental hemostatic risk factor for open heart surgery. METHODS The study included 97 patients who underwent elective coronary artery surgery (78 men and 19 women; mean age, 60.9 +/- 10.3). Preoperative blood samples were obtained and preoprative quantitative determination of plasma fibrinogen levels were measured by the clotting method of Clauss using the fibrinogen kit. Patients were operated on by the same team and the same technique. The total amount of drainage blood from chest tubes was recorded after termination of operation. RESULTS There were statistical significance between the fibrinogen levels and the drainage (r = -0.897, P < .001). Chest drainage was a mean of 972 mL (range, 240-2445 mL) in the first 48 hours after sternotomy closure. Fibrinogen level and relation to age was statistically significant (P = .015). There was no statistical significance between fibrinogen levels and gender (male gender = 400.7 +/- 123.0 versus female gender = 395.6 +/- 148.1; P = .877) and between drainage and gender (male gender = 968.2 +/- 538.5 versus female gender = 990.0 +/- 554.7; P = .876). Two patients (2%) died early after the surgery. There were no significant differences between the postoperative bleeding and cardiopulmonary bypass time (P = .648) or cross-clamp time (P = .974). CONCLUSION The results of this study suggested that low preoperative fibrinogen level appears to be a useful diagnostic marker to assess the activity of the coagulation system, and that its preoperative level may serve as a potential risk factor for postoperative bleeding after coronary artery bypass surgery.

Predictive significance of plasma levels of interleukin-6 and high-sensitivity C-reactive protein in atrial fibrillation after coronary artery bypass surgery.

BACKGROUND Postoperative atrial fibrillation (AF) plays a major role in the determination of hemodynamic deterioration and can be associated with cardiovascular events after coronary artery surgery. Elevated interleukin (IL)-6 and C-reactive protein (CRP) levels in patients with AF suggest a role of inflammation in the pathogenesis of AF. We conducted a study to investigate the correlation between postoperative AF and IL-6 and high-sensitivity CRP (hsCRP). MATERIALS AND METHODS Forty-nine patients with a mean age of 60.3 +/- 10.7 years were enrolled in this study. Preoperative and postoperative first day blood samples were collected to assess the IL-6 and hsCRP levels. IL-6 levels were measured by enzyme-linked immunosorbent assay, and hsCRP was measured by rate turbidimetry method. RESULTS Fourteen patients (28.5%) developed AF postoperatively. Patients who developed AF showed elevated serum concentrations of postoperative first day IL-6 (P < .001), preoperative hsCRP (P < .005), and postoperative first day hsCRP (P < 0.001). Preoperative hsCRP levels (P < .002) and postoperative first day IL-6 (P < .001) and hsCRP (P < 0.001) levels were associated with prolonged endotracheal intubation time. Prolonged intensive care unit stay showed significant correlations with elevated levels of preoperative hsCRP (P < 0.002) and postoperative first day IL-6 (P < 0.001) and hsCRP (P < 0.001). There was also statistical significance between the AF+ and AF- groups regarding intensive care unit stay and endotracheal intubation times (P < .001 and P < .001, respectively). Cut-off points for postoperative first day IL-6, preoperative hsCRP, and postoperative first day hsCRP were 46.4 pg/mL (sensitivity = 92.9% and specificity = 80%), 0.46 mg/L (sensitivity = 71% and specificity = 75%), and 17.9 mg/L (sensitivity = 92.9% and specificity = 78%), respectively. CONCLUSIONS Elevated IL-6 and hsCRP levels in patients with postoperative AF suggest inflammatory components have a role of in the pathogenesis of AF.

Hydroxyethyl starch 6%, 130/0.4 vs. a balanced crystalloid solution in cardiopulmonary bypass priming: a randomized, prospective study

BackgroundSince the advent of cardiopulmonary bypass, many efforts have been made to avoid the complications related with it. Any component of the pump participates in occurrence of these adverse events, one of which is the type of prime solution. In this study, we aimed to compare the effects of 6% hydroxyethyl starch 130/0.4 with a commonly used balanced electrolyte solution on postoperative outcomes following coronary bypass surgery.MethodsTwo hundred patients undergoing elective coronary bypass surgery were prospectively studied. The patients were randomized in to two groups. First group received a balanced electrolyte solution and the second group received 6% hydoxyethyl starch 130/0.4 as prime solution. The postoperative outcomes of the patients were studied.ResultsThe mean age of the patients was 61.81 ± 10.12 in the crystalloid group whereas 61.52 ± 9.29 in the HES group. There were 77 male patients in crystalloid group and 74 in HES group. 6% hydroxyethyl starch 130/0.4 did not have any detrimental effects on renal and pulmonary functions. The intensive care unit stay and postoperative hospital length of stay were shorter in hydroxyethyl starch group (p < 0.05 for each). Hydroxyethyl starch did not increase postoperative blood loss, amount of blood and fresh frozen plasma used, but it decreased platelet concentrate requirement. It did not have any effect on occurrence of post-coronary bypass atrial fibrillation (p > 0.05).Conclusions6% hydroxyethyl starch 130/0.4 when used as a prime solution did not adversely affect postoperative outcomes including renal functions and postoperative blood transfusion following coronary bypass surgery.

Heat shock protein70: a new marker for subsequent atrial fibrillation development?

Atrial fibrillation (AF) is a common arrhythmia, after cardiac surgery, and it is associated with a twofold increase in cardiovascular mortality and morbidity. Reperfusion injury and inflammation associated with cardiac surgery are thought to be involved in its pathogenesis. Heat shock proteins (HSPs) are a family of chaperone proteins which assist in preservation of cellular integrity by maintaining proteins in their correctly folded state. The aim of this study was to investigate pre-postoperative heat shock protein70 (HSP70) and high-sensitivity C-reactive protein in serum from patients in preoperative sinus rhythm. We prospectively screened 45 consecutive patients admitted to the hospital for elective coronary artery bypass surgery (CABG). Electrocardiogram characteristics and cardiovascular risk profile were documented. Pre- and postoperative blood samples were collected. HSP70 value was 8.9 +/- 4.8 ng/mL in Group A (study group) preoperatively and decreased to 7.7 +/- 7.0 ng/mL postoperatively. In contrast, preoperative value of HSP70 was 4.2 +/- 2.2 ng/mL and decreased to 2.7 +/- 2.6 ng/mL postoperatively in Group B (control group). Statistical analysis showed significant difference regarding preoperative HSP70 levels in Group A compared to Group B. To our knowledge, with this study, the association of pre- and postoperative circulating HSP70 with postoperative AF was demonstrated for the first time.

Comparison of effects of epidural bupivacaine and intravenous meperidine analgesia on patient recovery following elective abdominal aortic surgery

Background The efficacy of epidural anesthesia and analgesia in management of perioperative stress has been established. Perioperative pain management strategies decrease surgical complications and aid recovery. In this study, we aimed to document and compare the efficacy of epidural bupivacaine and intravenous meperidine on recovery of patients with elective abdominal aortic surgery performed under general anesthesia. Material/Methods Patients undergoing elective abdominal aortic surgery between February 2009 and November 2011 were studied prospectively. Patients were randomized into epidural bupivacaine (n=40) and intravenous meperidine (n=40) groups regarding postoperative analgesia strategy. The preoperative demographic characteristics, perioperative outcomes, postoperative adverse effects of analgesia strategy, time to initiate oral intake, sedation scores, visual analogue scale results, and mobility scores were compared. Results The mean ages of the patients were 61.7±8.1 in the epidural group and 59.4±9.7 in the intravenous group (p>0.05). The preoperative demographic characteristics of the patients were comparable between the groups. There were no statistically significant differences between groups regarding anesthesia times, intubation times, intensive care unit stay, hospital length of stay, postoperative vomiting, and postoperative cardiac, renal, and cerebral complications. Postoperative nausea was more prevalent in the meperidine group (p<0.05). In the epidural group, time to begin oral intake was shorter, sedation scores and visual analogue scale results were lower, and mobility scores were higher (p<0.05 each). Conclusions Epidural analgesia allowed earlier recovery compared to intravenous analgesia in patients undergoing elective abdominal aortic surgery, but did not affect postoperative outcomes and complications.

Ventilation during cardiopulmonary bypass did not attenuate inflammatory response or affect postoperative outcomes.

Introduction Cardiopulmonary bypass causes a series of inflammatory events that have adverse effects on the outcome. The release of cytokines, including interleukins, plays a key role in the pathophysiology of the process. Simultaneously, cessation of ventilation and pulmonary blood flow contribute to ischaemia–reperfusion injury in the lungs when reperfusion is maintained. Collapse of the lungs during cardiopulmonary bypass leads to postoperative atelectasis, which correlates with the amount of intrapulmonary shunt. Atelectasis also causes post-perfusion lung injury. In this study, we aimed to document the effects of continued low-frequency ventilation on the inflammatory response following cardiopulmonary bypass and on outcomes, particularly pulmonary function. Methods Fifty-nine patients subjected to elective coronary bypass surgery were prospectively randomised to two groups, continuous ventilation (5 ml/kg tidal volume, 5/min frequency, zero end-expiratory pressure) and no ventilation, during cardiopulmonary bypass. Serum interleukins 6, 8 and 10 (as inflammatory markers), and serum lactate (as a marker for pulmonary injury) levels were studied, and alveolar–arterial oxygen gradient measurements were made after the induction of anaesthesia, and immediately, one and six hours after the discontinuation of cardiopulmonary bypass. Results There were 29 patients in the non-ventilated and 30 in the continuously ventilated groups. The pre-operative demographics and intra-operative characteristics of the patients were comparable. The serum levels of interleukin 6 (IL-6) increased with time, and levels were higher in the non-ventilated group only immediately after discontinuation of cardiopulmonary bypass. IL-8 levels significantly increased only in the non-ventilated group, but the levels did not differ between the groups. Serum levels of IL-10 and lactate also increased with time, and levels of both were higher in the non-ventilated group only immediately after the discontinuation of cardiopulmonary bypass. Alveolar–arterial oxygen gradient measurements were higher in the non-ventilated group, except for six hours after the discontinuation of cardiopulmonary bypass. The intubation time, length of stay in intensive care unit and hospital, postoperative adverse events and mortality rates were not different between the groups. Conclusion Despite higher cytokine and lactate levels and alveolar–arterial oxygen gradients in specific time periods, an attenuation in the inflammatory response following cardiopulmonary bypass due to low-frequency, low-tidal volume ventilation could not be documented. Clinical parameters concerning pulmonary and other major system functions and occurrence of postoperative adverse events were not affected by continuous ventilation.

Giant right atrial myxoma mimicking hepatic cirrhosis: a case report.

Cardiac myxomas are rare benign tumors of the heart. The growth rate of these tumors remains unknown. Right atrial myxoma can simulate nonspecific constitutional symptoms, such as remittent or lasting fever, weight loss, and chronic anemia, and may escape timely diagnosis until the development of severe complications such as pulmonary hypertension due to embolism from fragments originating from the tumor mass or blockage of the right atrioventricular ostium or Budd-Chiari syndrome with acute abdominal pain. We present a case of a giant right atrial myxoma mimicking hepatic cirrhosis in a 52-year-old man.

Obesity is still a risk factor in coronary artery bypass surgery.

OBJECTIVE Even with the improvements in surgical techniques and perioperative care, obesity is still a risk factor for occurrence of adverse events following cardiac surgery. In this observational, retrospective study, we aimed to document the effects of obesity on surgical outcomes in patients undergoing coronary artery bypass surgery and find out the effects of improvements in cardiac surgery. METHODS Between January 2011 and March 2013, isolated coronary artery bypass surgery was performed on 790 patients. The body mass index values of the patients were calculated and patients were divided into two groups; below 30 were classified as non-obese group whereas above 30 were classified as obese group. The odds ratio was obtained by using univariate analysis in order to document the effects of obesity on outcomes. RESULTS There were 548 (69.3%) patients in non-obese group, whereas 242 (30.7%) patients in obese group. The cardiopulmonary bypass (80.47±23.58 vs. 80.89±28.46, p=0.449) and aortic clamp times (54.13±16.60 vs. 54.19±19.85, p=0.511) and number of bypass grafts (3.09±1.02 vs. 2.96±1.00, p=0.11) were comparable between the groups. The mean number of fresh frozen plasma used was higher in obese patients (1.37±1.75 vs. 1.48±4.63, p=0.02). Intubation time was higher in obese patients (10.57±6.87 vs. 12.71±35.31, p=0.014). Total amount of postoperative drainage was higher in non-obese patients (766.77±472.27 vs. 648.72±371.39, p<0.001). The superficial infection/mediastenitis (0.4% vs. 2.5%, p=0.012), dehiscence (0.2% vs. 3.7%, p<0.001) and postoperative renal failure rates (4.7% vs. 8.7%, p=0.031) were higher in obese patients. The incidence of atrial fibrillation was lower in obese patients (19.7% vs. 12.8%, p=0.019). The mortality (0.5% vs. 1.7%, p=0.210) and postoperative stroke rates (1.1% vs. 0.8%, p=1.000) were similar in both groups. CONCLUSION We documented that obesity is still a risk factor for occurrence of postoperative adverse events. We believe that improved perioperative care together with meticulous regimens can improve postoperative outcomes in patients undergoing coronary artery bypass surgery.

Plasma leptin levels increase to a greater extent following on-pump coronary artery surgery in type 2 diabetic patients than in nondiabetic patients

AIMS We aimed to evaluate whether leptin and ghrelin responses to cardiopulmonary bypass (CPB) are dependent on type 2 diabetes and whether these responses are associated with interleukin-6 (IL-6), high-sensitivity C-reactive protein (hsCRP), cortisol and insulin. METHODS We examined stress-response patterns in plasma leptin, ghrelin, hsCRP, IL-6, cortisol and insulin levels before and up to 5 days after cardiopulmonary bypass in 20 patients with type 2 diabetes and 20 patients without diabetes. RESULTS Plasma leptin levels increased significantly in both groups (p<0.05) and rose significantly higher in diabetics when compared with nondiabetic patients (p=0.004). Plasma ghrelin levels increased significantly only in diabetics (p=0.033). Patients with and without diabetes showed significantly elevated serum concentrations of IL-6, hsCRP, cortisol and insulin (p<0.005 for IL-6, hsCRP; p<0.05 for cortisol, insulin) but the difference between the two groups was nonsignificant. Leptin was independently predicted by hsCRP (p<0.05, F=2.9), gender (women p<0.001, F=4.7), body mass index (BMI p<0.0001, F=6.1) whereas ghrelin levels were not associated with any variables in the total patient population. (critical F=2.26, p≤0.05). CONCLUSIONS Acute phase response in diabetics differs by higher leptin levels independent of BMI, gender and IL-6, hsCRP, insulin and cortisol levels.

Does the anatomy of mitral paravalvular leakage increase the risk of device embolization in percutenous treatment modalities

The publication by Guler et al. [1] highlights a very problematic area in valvular surgery, the treatment of paravalvular leakage (PVL). They successfully treated mitral PVL transapically in a highrisk patient with an Amplatzer duct occluder device. They avoided all the known complications of redo surgery and the additional risks that might be brought by the comorbidities of the patient. The relation of the PVL with the hinge points of the prosthetic valve was very well emphasized, which is one of the most important determinants of procedural success rates. They also used three-dimensional transoesophageal echocardiography and demonstrated the procedure with excellent pictures. In this valuable report, there is a particular topic we would like to discuss. We know that mitral PVL has a detrimental course, especially compared with aortic PVL (16 ± 8 vs 70 ± 12% event-free survival rates in 8 years) [2]. This finding mandates immediate therapeutic intervention. In percutenous modalities of PVL occlusion, there is no real rim-like atrial septum. The anatomy may increase the tendency for residual leakages after the first occluder deployment. In addition, this strategy, particularly in the aortic position, may cause a new PVL in the anterior or posterior aspect of the device, which may require a second or third occluder implantation and even embolization after first occluder implantation. Therefore, the size of the connector that connects both discs should be of the same diameter as the defect. Sriratanaviriyakul et al. [3] reported a similar case in which they had to implant a second occluder device. So, it should be emphasized that, due to anatomical features, size matters in occluder device treatment of PVLs to prevent secondary leakages and possible embolization. Because, as the number of implanted occluder devices increase due to unfavorable anatomy, the risk of embolization will also increase. Embolized occluder devices, even in simple secundum atrial septal defects, increase the mortality 20-fold compared with elective surgery [4]. In conclusion, we believe that interventional treatment modalities of PVL will save patients’ lives with decreased adverse event rates. We would like to congratulate the authors for their success and thank them for sharing their experience with the readers.