Harun Tatar

Timing of replacement therapy for acute renal failure after cardiac surgery.

Abstractu2003 Objective: Acute renal failure (ARF) following cardiac surgery remains a significant cause of mortality. The aim of this study is to compare early and intensive use of continuous veno‐venous hemodiafiltration (CVVHDF) with conservative usage of CVVHDF in patients with ARF after cardiac surgery. Materials and Methods: Due to ARF, CVVHDF was required in two groups of a total of 61 adult patients (1.79% of all patients). Group 1 included 27 patients while Group 2 included 34 patients. CVVHDF was performed on Group 1 when creatinine level exceeded 5 mg/dL, or potassium level exceeded 5.5 mEq/L irrespective of the urine output. CVVHDF was performed on Group 2 when urine output was less than 100 mL within consecutive 8 hours, with no response to 50 mg furosemide with the supplementary criterion that urine sodium concentration should be >40 mEq/L before the administration of furosemide. Results: The mean elapsed time between the surgery and the initiation of CVVHDF was 2.56 ± 1.67 days in Group 1 and 0.88 ± 0.33 days in Group 2 (p = 0.0001). The mean intensive care unit (ICU) stay for Group 1 was 12 ± 3.44 days and 7.85 ± 1.26 days for Group 2 (p = 0.0001). ICU mortality rate was 48.1% for Group 1 and 17.6% for Group 2 (p = 0.014). The overall hospital mortality rate was 55.5% for Group 1 and 23.5% for Group 2 (p = 0.016). Conclusion: Recognition of ARF and early beginning of the CVVHDF are extremely important. The sooner the ARF after surgery is recognized and CVVHDF is performed, the higher the likelihood of the reduction of the hospital mortality. (J Card Surg 2004;19:17‐20)

Tricuspid insufficiency does not increase early after permanent implantation of pacemaker leads.

Abstractu2002 Background: Interference between pacemaker (PM) lead and tricuspid apparatus may cause tricuspid regurgitation (TR). However, data regarding TR in patients with implanted PM are controversial. Our aim is to find out the degree of TR in a group of patients before and following PM implantation in a prospective manner. Methods: The study group consisted of the patients referred for implantation of permanent PM or implantable cardioverter defibrillator (ICD). All patients underwent two‐dimensional and Doppler echocardiographic evaluation before and after device implantation. The severity of TR was qualitatively classified into four groups as normal or trivial, mild, moderate, or severe. All studies were reviewed for accuracy by a second independent interpreter. Results: Sixty‐one patients (mean age 53 ± 8 years, 44 male) referred for PM (n = 55) or ICD (n = 6) implantation consisted of the study population. Echocardiographic degree of TR was mild in 21 (70%), moderate in 7 (23%) and severe in 2 (7%) patients before PM implantation. Following device implantation, mild TR was noted in 23 (76%), moderate in 10 (33%), and severe in 2 (6%) cases. After the procedure, the TR severity was increased from normal/trivial to mild in 5 (16%) cases and from mild to moderate in 3 (10%). There was no worsening of the severity of TR in patients with moderate regurgitation following device implantation. The severity of TR did not change at a mean follow‐up of 6 ± 3 months. Conclusions: New or worsening TR is relatively rare after PM implantation. It is not associated with an acute worsening or clinical deterioration. But echocardiographic follow‐up is recommended to monitor other complications in chronic phase.

The Effect of Oral Prednisolone with Chronic Obstructive Pulmonary Disease Undergoing Coronary Artery Bypass Surgery

Abstractu2003 Background: Chronic obstructive pulmonary disease is still one of the most important problems in patients undergoing cardiopulmonary bypass. The purpose of this prospective study was to assess the beneficial effects of oral prednisolone on pulmonary functions in patients undergoing cardiopulmonary bypass. Methods: Forty patients with chronic obstructive pulmonary disease were divided into two groups randomly and were given 20 mg oral prednisolone once daily perioperatively (Group I, n = 20) or identical placebo (Group II, n = 20). FEV1 values, dates of intensive care unit and hospital stays of the two groups were compared. Results: FEV1 values during the admission to our hospital were similar in each group mean predicted FEV1: 56.7 ± 5.35% in Group I and 57.2 ± 4.88% in Group II (p = 0.759). After 10 days of oral prednisolone treatment in Group I, predicted FEV1 values were significantly different between two groups (63.2%± 4.24 and 57.9%± 4.38) (p = 0.0001). While predicted FEV1 values revealed difference between two groups at the date of discharge (p = 0.0001) the values became similar at the third month (55.6%± 4.09 in Group I and 55.45%± 3.87 in Group II) (p = 0.897). Conclusion: Various types of complications may occur after cardiopulmonary bypass. Oral prednisolone not only decreases the rates of complications (reintubation, intubation times, and rhythm disturbances) but also decreases the cost of cardiac operations according to shorter hospital stays.

Mid‐Term Angiographic Comparison of Sequential and Individual Anastomosis Techniques for Diagonal Artery

Abstractu2003 Objective: The mid‐term patency rates for individual and sequential grafts as coronary bypass conduits for diagonal arteries were angiographically compared; the impact of native coronary vessel and type of the conduit characteristics are investigated. Methods: Between March 1992 and April 2000, we performed a total number of 811 distal anastomosis on diagonal arteries of left anterior descending (LAD) artery in 296 patients who underwent coronary artery bypass surgery (CABG) distal anastomosis in our clinic. The patients were divided into two groups in this prospective study. In group A (n = 195) individual anastomosis technique, in group B (n = 101) sequential anastomosis technique was chosen as the myocardial revascularization strategy. At an average of 49.4 ± 13.2 months after coronary revascularization procedure coronary angiographies were evaluated. Individual and sequential grafting techniques were compared by graft patency rates. Results: The patency rates of sequential conduits were markedly higher than those of individual conduits (66.7% vs. 89.2%, p = 0.0001). This difference was also clear in coronary arteries with poor quality and small (<1.5 mm) diameter (49.1% vs. 66.6%, p = 0.032). Also, the patency rates of sequential radial artery conduits were higher than sequential saphenous vein graft (SVG) conduits (sequential radial artery; 94.1%, sequential SVG; 85.3%, p = 0.043). Conclusions: Sequential grafting for diagonal artery is technically more demanding but the mid‐term results are better than individual grafting especially in coronary arteries with poor quality. Using radial artery as a sequential graft increases the mid‐term graft patency rates.

Both leaflet preservation during mitral valve replacement: modified anterior leaflet preservation technique.

Abstractu2003 Background: Satisfactory results of bileaflet preserving mitral valve replacement (MVR) had forced several institutes to preserve both leaflets during MVR. Modifications were required to prevent the preserved tissue from interfering with prosthetic valve function, to implant an adequate size of valve and to prevent left ventricle outflow tract (LVOT) obstruction. Materials and Methods: Conventional MVR was performed to 51 patients (group 1) and bileaflet preserving MVR was performed to 43 patients (group 2). Mitral anterior leaflet incised from the middle of the leaflet to mitral annulus without chordal injury in group 2 patients. Sutures were placed through the mitral annulus first and then passed from the bottom to the tip of anterior leaflet. Posterior leaflet was also preserved. Prosthetic valve was put down into the mitral annulus and sutures were ligated. Excessive anterior leaflet tissue was attached to left atrial wall. Results: Cross‐clamping time was 45 ± 5.33 minutes versus 61.32 ± 4.43 minutes (p = 0.0001) and total cardiopulmonary bypass time was 60.80 ± 4.44 minutes versus 80.55 ± 3.65 minutes (p = 0.0001) in groups 1 and 2, respectively. Inotropy requirement was higher in group 1 (p = 0.0058). When compared with preoperative values postoperative left ventricle ejection fraction (LVEF) increased both at rest (from 52.74%± 3.88% to 62.86%± 3.18%, p = 0.0001) and during exercise (from 53.16%± 3.16% to 64.11%± 2.46%, p = 0.0001) in bileaflet preserving MVR group. But in conventional MVR group LVEF decreased postoperatively both at rest (from 51.45%± 4.27% to 48.27%± 3.35%, p = 0.0001) and during exercise (from 54.47%± 7.36% to 42.96%± 3.58%, p = 0.0001). Conclusion: Leaflet preserving MVR operation not only improves the left ventricular performance but also reduces the mortality and morbidity after MVR. LVEF increases both at rest and during exercise. Risk of LVOT obstruction can be completely eliminated with our simple technique.

Prediction of Intraoperative Hypovolemia in Patients with Left Ventricular Hypertrophy: Comparison of Transesophageal Echocardiography and Swan‐Ganz Monitoring

We have compared the pulmonary artery catheterization and transesophageal echocardiography (TEE) as an index of left ventricular (LV) volume in 32 patients with LV hypertrophy. Twenty‐four of the 32 patients had episodes of low LV volume using TEE. Of these 24 patients, five had low pulmonary capillary wedge pressures ranging from 6–11 mmHg (mean ± SD, 8.8 ± 1.9 mmHg). Nineteen patients had elevated pulmonary capillary wedge pressures (PCWPs) (mean 18.3 ± 2.2 mmHg) and TEE showed signs of hypovolemia. Volume repletion resulted in increased blood pressure in these patients. The poor correlation between PCWP and LV end‐diastolic volume in the present study may result from impaired compliance of the ventricle. Diagnosis of hypovolemia should not be solely based on hemodynamic parameters alone and TEE provides accurate estimates of ventricular volume.

Coronary Artery Bypass Surgery in Patients with Malignancy: A Single-Center Study with Comparison to Patients Without Malignancy

Abstractu2002 Background: There is debate on the timing and outcome of coronary artery bypass surgery in patients with coincident malignancy. In this study, we compared the outcome of coronary artery bypass graft (CABG) in such patients with those without malignancy. Methods: The patients were selected from those who had undergone coronary artery bypass surgery in the last decade. The study group (group I) included the patients with malignancy in remission. The control group comprised those patients who were selected randomly from those without any malignancy. The patients were retospectively examined with regard to preoperative, operative, and postoperative data from personal files, computerized recording system, and operation reports. Results: Group I included 48 patients (age 48 to 69; 29 male) while group II included 50 patients (age = 38 to 73; 35 male). In group I, comorbidity rates were: renal dysfunction in 12 (25%), obstructive lung disease 10 (21%), congestive failure in four (8%) patients. The malignancy rates were: lung in 15 (31%), breast in 10 (21%), stomach in five (10%), colon in four (8%), renal in one (2%), Hodgkins lyphoma in three (6%), leukemia in two (4%), ovarian in three (6%), and prostate in five (10%) patients. In group II, the comorbidity rates were: diabetes mellitus 18 (36%), renal dysfunction in five (10%) and obstructive lung disease in 13 (26%) patients. In group I, chemotherapy and radiotherapy were performed in 38 and 34 patients, respectively. In groups I and II, the CABG was elective in 47 (98%) and in 45 patients (90%); the off‐pump surgery was performed in 27 (56%) and 12 (24%) patients, respectively. The total duration of bypass was 37 ± 6 minutes and 44 ± 5 minutes; the duration of aortic clamp was 26 ± 4 and 29 ± 7 minutes, respectively, in groups I and II. Posoperative complication rates were: infection in 12 (25%), bleeding in eight (17%), acute renal insufficiency in eight (17%), prolonged air escape in five (10%), and prolonged entubation in 17 (35%) patients in group I and atrial fibrillation in 11 (22%) patients in group II. Mortality rates in both groups were two (4%). Conclusion: CABG in patients with comorbid malignancy is as safe as the other patients. In patients with full remission of malignancy, the surgeons should be encouraged about the safety of CABG.

Harvesting of the Radial Artery: Subfasciotomy or Full Skeletonization: A Comparative Study

Abstractu2002 Background: Long fasciotomy of the posterior aspect of the radial artery (RA) for the purpose of sympathectomy is one of the surgical techniques for the preparation of this graft. We compared the early results of this technique with those of the RA graft harvested as a pedicle in the conventional fashion.

A complication of coronary angiography: fractured and retained intraaortic catheter.

Abstractu2003 The complications linked directly to coronary artery catheter itself are very rare. We presented a case in which the broken right coronary artery catheter was successfully removed from the ascending aorta. The removal of catheter was accomplished via an aortic incision, which was created for saphenous vein graft in the site of anastomosis during an emergency coronary artery bypass graft surgery. We believe that a broken catheter in the aorta is a catastrophic event, which could be removed safely in the operating room even with concomitant bypass surgery.

Is the Visual Examination of LIMA Graft Sufficient for the Decision Reusing of This Graft in Redo Coronary Bypass Surgery

Abstractu2003 Redo coronary artery bypass grafting (CABG) compromises a growing proportion of CABG in the current era of revascularization. Intimal hyperplasia at the site of anastomosis between left internal mammary artery (LIMA) and left anterior descending artery (LAD) is not infrequently reported causing severe ischemic symptoms in some patients. An additional grafting to distal LAD territory is a proper decision for the surgical strategy in most of the cases. Radial artery or venous grafts have been used for this purpose. Shortage of arterial grafts is the major concern in redo coronary surgery. Whether the previously anastomosed LIMA can be used is a major question in decision‐making process. In this case report, we presented a complicated patient in whom LIMA was not reused although visual or angiographical examination was normal.