Halil Türkoğlu

Postoperative prophylactic peritoneal dialysis in neonates and infants after complex congenital cardiac surgery.

Peritoneal dialysis after complex congenital cardiac surgery was introduced to a group of neonates and infants (n = 756; age, 0 to 1 year) between May 1993 and December 2005. Indications of peritoneal dialysis were determined as well as methods, prolonged dialysis, and its outcomes. Demographic characteristics, preoperative risk factors, intraoperative variables, and postoperative complications were compared in 756 cases with ages below 1 year. All cases underwent ultrafiltration during the perioperative stage. One hundred eighty-six cases (24.6% of total) required peritoneal dialysis. The cardiac pathology was transposition of great arteries in 133 cases, tetralogy of Fallot in 37, aorticopulmonary window associated with interrupted aortic arch in 4 and total anomalous pulmonary venous return in 5, and other complex pathology in 7 cases. Prolonged peritoneal dialysis was usually required in infants with low weight, with episodes of pulmonary hypertensive crisis (p < 0.05), and with preoperative renal dysfunction. No major complication was observed related to the peritoneal dialysis catheter. Of 186 patients, 23 (12.3%) had acute renal failure, and 4 of them died (2.15% of all patients underwent operation, 17.3% of those with acute renal failure). It has been demonstrated that the combination of peritoneal dialysis with perioperative ultrafiltration application was effective in providing the required postoperative negative fluid balance in especially complex congenital heart cases and affected survival positively.

Benefits of pulsatile perfusion on vital organ recovery during and after pediatric open heart surgery.

Controversy continues concerning the utilization of pulsatile flow during cardiopulmonary bypass (CPB) procedures with regard to improved patient outcomes. We evaluated 215 consecutive pediatric patients undergoing open heart surgery for repair of congenital heart disease who were prospectively entered into the study and randomly assigned to either the pulsatile perfusion group (group P, n = 151) or the nonpulsatile perfusion group (group NP, n = 64). All patients received identical surgical, perfusional, and postoperative care. Major complications and clinical outcome were documented. There were no statistically significant differences seen in either preoperative or operative parameters between the two groups (age, body surface area, weight, X-clamp and CPB time, base flow, flow rates, and hemofiltration). Group P, compared with group NP, had significantly less inotropic support (number of agents 1.4 ± 0.07 vs. 2 ± 0.12, p = 0.0012; dopamine 7.14 ± 0.28 vs. 9.04 ± 0.42 &mgr;g 32 · kg−1 · min−1, p = 0.00025; dobutamine 4.12 ± 0.3 vs. 5.3 ± 0.6 &mgr;g 32 · kg−1 · min−1, p = 0.036), adrenalin (0.026 ± 0.005 vs. 0.046 ± 0.005 &mgr;g 32 · kg−1 · min−1, p = 0.021), shorter intubation period (10.26 ± 1.04 vs. 18.64 ± 1.99 hours, p = 0.021), shorter duration of intensive care unit (ICU) (1.53 ± 0.07 vs. 2.75 ± 1.19 days, p = 0.012), and hospital stay (6.71 ± 0.19 vs. 11.16 ± 0.58 days, p = 0.002). Although there were no significant differences in either creatinine, enzyme levels, and drainage amounts between two groups, lower lactate levels 16.27 ± 2.02 vs. 24.66 ± 3.05 mg/dl, p = 0.00034), higher albumine levels (3.15 ± 0.03 vs. 2.95 ± 0.06 mg/dl, p = 0.046), and higher urine output (602.82 ± 21.5 vs. 505.55 ± 34.2 ml/d, p = 0.016) during ICU period was observed in group P compared with group NP, respectively. We concluded that the use of pulsatile flow resulted in improved patient outcomes in terms of preserving better cardiac, renal, and pulmonary functions in the early post-CPB period.

Effects of Pulsatile and Nonpulsatile Perfusion on Vital Organ Recovery in Pediatric Heart Surgery: A Pilot Clinical Study

The use of pulsatile flow during cardiopulmonary bypass (CPB) with regard to improved patient outcomes is controversial. We evaluated pulsatile perfusion in pediatric patients undergoing CPB in a clinical setting. Fifty consecutive pediatric patients undergoing open heart surgery for repair of congenital heart disease were prospectively entered into the study and randomly assigned to either the pulsatile perfusion group (group P, n = 25) or the nonpulsatile perfusion group (group NP, n = 25). Study parameters included intubation time, duration of intensive care unit (ICU) stay and hospital stay, need for inotropic support, preoperative and postoperative enzymes, creatinine, C-reactive protein, blood count, mean urine output, and total drainage. Group P, compared with group NP, had significantly less inotropic support (number of agents, 1.48 ± 1.05 versus 2.44 ± 1.03, p = 0.0015; dopamine, 6.48 ± 3.27 versus 10.3 ± 4.8 &mgr;g/kg per minute, p = 0.0023; dobutamine, 3.12 ± 6.55 versus 8.03 ± 9.1 &mgr;g/kg per minute, p = 0.034), shorter intubation period (20.36 ± 17.02 versus 35.44 ± 30.72 hours, p = 0.038), and shorter duration of ICU stay (2.16 ± 1.07 versus 4.32 ± 4.21 days, p = 0.028) and hospital stay (7.64 ± 2.48 versus 11.84 ± 6.82 days, p = 0.007). There were no significant differences in creatinine, enzyme levels, or drainage amounts between the two groups. Higher urine output during CPB (553.6 ± 150.89 versus 465.8 ± 151.23 ml/d, p = 0.045) and during the ICU period (658.8 ± 210.99 versus 528,2 ± 224.71 ml/d, p = 0.039) was observed in group P compared with group NP. We concluded that the use of pulsatile flow resulted in improved patient outcome in preserving cardiac function and maintaining better renal and pulmonic function (shorter intubation period) in the early postbypass period.

Impact of Pulsatile Perfusion on Clinical Outcomes of Neonates and Infants With Complex Pathologies Undergoing Cardiopulmonary Bypass Procedures

The aim of this clinical trial was to evaluate the pulsatile perfusion mode in pediatric patients who had complex cardiac pathologies according to Jenkins stratifications (category 4) undergoing cardiopulmonary bypass procedures (CPB). Patients with transposition of great arteries (TGA) and ventricular septal defect (VSD) were included in this clinical study. Eighty-nine consecutive pediatric patients undergoing open heart surgery for repair of TGA-VSD were prospectively entered into the study and were randomly assigned to either the pulsatile perfusion group (Group P, n = 58) or the nonpulsatile perfusion group (Group NP, n = 31). There were no differences between groups in terms of demographical and intraoperative parameters. The pulsatile group needed significantly less inotropic support (P < 0.05) and had lower lactate levels (P < 0.001), higher urine output (P < 0.01), and higher albumin levels (P < 0.05). In addition, the pulsatile group had less ICU (P < 0.01) and hospital stays (P < 0.001). We conclude that the use of pulsatile flow is a better option and should be considered for repair of the complex congenital heart defects.

Atrial natriuretic peptide: could it be a marker for postoperative recurrent effusions after Fontan circulation in complex congenital heart defects?

Fontan operation and its modifications are used for the physiological correction of complex congenital heart malformations with functionally single ventricle. Atrial natriuretic peptide (ANP), a physiological diuretic and vasodilator that—together with the effects of cardiopulmonary bypass—plays an important role in the augmentation of capillary permeability in Fontan patients. The rise in right atrial pressure and wall stress is an important stimulus for the release of ANP. ANP levels were measured before and early after surgery in Fontan group (n = 20) and control group (n = 20, patients with simple cardiac defects) to study its influence on and association with mean right atrial pressure, pulmonary vascular resistance (PVR), systemic vascular resistance, amount of drainage during early and late postoperative period, duration of intensive care unit and hospital stay, and need for colloid supplement. Early postoperative ANP values showed a negative correlation with PVR (r = –0.55) and total drainage (r = –0.88). There was no significant change in ANP during surgery or in the postoperative period in control patients. Reduction of PVR and maintenance of efficient urine output are important in the management of Fontan circulation. We conclude that high levels of ANP measured early after Fontan operation can be used as a marker for the successful establishment of Fontan circulation in patients with complex congenital heart defects.

Correlation between cerebral-renal near-infrared spectroscopy and ipsilateral renal perfusion parameters as clinical outcome predictors after open heart surgery in neonates and infants.

The objective of this clinical study is to determine whether correlation exists among cerebral and renal near-infrared spectroscopy (NIRS) measurements, renal Doppler ultrasonography parameters (resistive index, peak systolic velocity), and early postoperative clinical outcomes following cardiac surgery in neonates and infants. Thirty-seven patients undergoing surgery for congenital heart defects with an age of less than 3 months, all of whom were in the high-risk group according to Aristotle Basic Complexity risk stratification score, were enrolled in our study. Cerebral, renal NIRS values and renal Doppler ultrasonography measurements were recorded for each patient at the 4th postoperative hour. The renal resistive indices were calculated for each case, and the patients were divided into two groups according to renal resistive index (RI) values. Group I included the patients with a RI of greater than 0.8 (n = 25) and Group II included the patients with a RI of less than 0.8 (n = 12). The postoperative outcome parameters were compared in between two groups. Group I (RI >0.8) had lower postoperative mean urine output than Group II (RI <0.8) (P = 0.041). The lactate levels were significantly higher in Group I (P = 0.049), as well. The postoperative intensive care unit and hospital stay of Group I was significantly higher than Group II (P = 0.048). Both cerebral and renal NIRS values and the assessment of renal RI as well as peak systolic values can be used in order to predict the early clinical outcome in cardiac surgery patients in early infantile and neonatal period.

Cardiac Surgery of Premature and Low Birthweight Newborns: Is a Change of Fate Possible?

Low birthweight (LBW) continues to be a high-risk factor in surgery for congenital heart disease. This risk is particularly very high in very low birthweight infants under 1500g and extremely LBW infants under 1000g. From January 2005 to December 2008, 33 consecutive LBW neonates underwent cardiac surgery in our clinic in keeping with the criteria for choice of surgery. Their weight range was between 800 and 1900g. Nine of them were under 1000g. Cardiopulmonary bypass (CPB) was used in 17 patients (39.5%) and pulsatile perfusion mode was applied to patients in the CPB group. The same surgical team operated to achieve palliation (8 patients, 24.2%) or full repair (25 patients, 75.8%). Median gestational age was 36 weeks with 12 (36.4%) premature babies (≤37 weeks). Median age at operation was 5 days. Pathologies were single ventricle (n=3), pulmonary atresia-ventricular septal defect (n=3), aortic coarctation (n=10), aorticopulmonary window and interrupted aortic arch combination (n=6), patent arterial duct (n=11), critical aortic stenosis (n=8), and tetralogy of Fallot with pulmonary atresia (n=2). One infant had VATER syndrome. Selective cerebral perfusion technique was used in complex arch pathologies for cerebral protection. Median follow-up was 14 months. There were four early postoperative deaths. None of the cases showed a need for early reoperation. The acceptable early- and midterm mortality rates in this group suggest that these operations can be successfully performed. There is a need for further multicenter studies to evaluate these high-risk groups.

Symptomatic lipoma in the interventricular septum.

Cardiac lipomas, which are benign nonmyxomatous neoplasms of the heart, are rare and among those least often encountered. Because they normally cause no symptoms, diagnosis is often purely accidental. We report the case of a 24-year-old woman who presented with palpitations of recent onset and was found to have a lipoma attached to the left side of the interventricular septum (IVS). Transthoracic and transesophageal echocardiograms were performed and showed a mass in the left side of the IVS. During successful surgical excision of the mass, intraoperative histologic diagnosis showed the tumor was lipoma. Our review of the English literature revealed that our case is only the seventh of removal of lipoma in the IVS. The postoperative course was uneventful, and an echocardiogram taken 6 months after the operation showed no evidence of enlargement of the tumor tissue.

Combined internal mammary artery graft for coronary artery revascularization

Five patients with multiple-vessel coronary artery disease underwent isolated coronary artery bypass grafting with a technique involving both internal mammary arteries and a small piece of interposed saphenous vein. The combined internal mammary artery grafts were used for sequential grafting. A total of 20 anastomoses were performed (average number, 4 anastomoses per patient). There were no operative deaths. Postoperative complications included reoperation for bleeding in 1 patient and diaphragmatic dysfunction in another. Postoperative coronary angiography 2 days before discharge (mean time, 10 days postoperatively) revealed that all the sequential anastomoses with the combined IMA graft were patent. Exercise tolerance tests performed 3 and 11 months postoperatively indicated excellent results and no ischemia. Based on this experience, we conclude that this method appears promising for multivessel coronary artery bypass grafting.

Allogeneic stem cell transplantation in a blast‑phase chronic myeloid leukemia patient with carbapenem‑resistant Klebsiella pneumoniae tricuspid valve endocarditis: A case report

In chronic myeloid leukemia (CML), the occurrence of blastic transformation is rare. Treatment outcome is generally poor. Allogeneic stem cell transplantation (allo-SCT) is the only potentially curative treatment option for advanced-phase CML. Infections caused by carbapenem-resistant Klebsiella pneumoniae (CRKP) isolates are associated with high morbidity and mortality rates, particularly in patients with haematological malignancies. Infection and colonization by these multiresistant bacteria may represent a challenge in SCT recipients for the management of post-transplantation complications, as well as for the eligibility to receive a transplant in patients who acquire the pathogen prior to the procedure. We herein report the case of a blast-phase CML patient with a highly resistant, CRKP-associated tricuspid valve endocarditis, who was treated with a combination of systemic antimicrobial therapy and surgical valve repair, and subsequently underwent a successful allo-SCT.