Hasim Ustunsoy

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.

Treatment outcomes of postoperative mediastinitis in cardiac surgery; negative pressure wound therapy versus conventional treatment

BackgroundThe aim of the present study is to compare negative pressure wound therapy versus conventional treatment outcomes at postoperative mediastinitis after cardiac surgery.MethodsBetween January 2000 and December 2011, after 9972 sternotomies, postoperative mediastinitis was diagnosed in 90 patients. The treatment modalities divided the patients into two groups: group 1 patients (n = 47) were initially treated with the negative pressure wound therapy and group 2 patients (n = 43) were underwent conventional treatment protocols. The outcomes were investigated with Kaplan-Meier method, log-rank test, Student’s test and Fisher’s exact test.ResultsThe 90-days mortality was found significantly lower in the negative pressure wound group than in the conventionally treated group. Overall survival was significantly better in the negative pressure wound group than in the conventionally treated group.ConclusionNegative pressure wound therapy is safe and reliable option in mediastinitis after cardiac surgery, with excellent survival and low failure rate when compared with conventional treatments.

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.

Pulmonary Valve Implantation With the New Shelhigh Injectable Stented Pulmonic Valve

BACKGROUND Pulmonary regurgitation (PR) occurs frequently after tetralogy of Fallot (TOF) repair, impairing long-term prognosis and necessitating reinterventions. Myocardial damage, invasiveness, and the risks of pulmonary valve replacement (PVR) therefore need to be minimized. The new Shelhigh Injectable Stented Pulmonic Valve (Shelhigh Inc, Union, NJ) allows implantation without cardiopulmonary bypass (CPB) under direct control. METHODS Twelve symptomatic patients (age, 21.3 +/- 12.5; range, 5.8 to 53.5 years) with severe PR and progressive right ventricular (RV) dilatation with dysfunction received the Shelhigh valve in sizes 21 (n = 1), 25 (n = 4), 27 (n = 3), 29 (n = 2), and 31 mm (n = 2). RESULTS Valve insertion was successful and hemodynamic performance excellent in all: peak systolic gradient, 14.5 +/- 4.6 (range, 10 to 20) mm Hg; mean gradient, 6.3 +/- 1.6 (range, 4 to 8) mm Hg. Four patients underwent concomitant procedures on CPB: one reduction plasty of a dilated main pulmonary artery, two tricuspid valve repairs, and one VSD closure. Early recovery was uneventful. There were no reoperations. During a mean follow-up of 5.4 +/- 4.3 months (range, 0.3 to 10.6 months) echocardiography showed good results, with low gradients and recovered RV function in all. All presented in New York Heart Association functional class 1 at the latest follow-up. CONCLUSIONS The Shelhigh valve allows easy PVR without CPB up to large valve sizes, with less invasiveness compared with a conventional approach. Further follow-up is needed to assess its durability and long-term performance.

Urgent surgical management for embolized occluder devices in childhood: single center experience

BackgroundIn this study, we sought to analyze our experience in urgent surgical management for embolized cardiac septal and ductal occluder devices resulting from trans-catheter closure of atrial septal defect, ventricular septal defect and patent ductus arteriosus in childhood patient group.MethodsWe retrospectively reviewed 9 patients (aged 2–15 years) who underwent urgent surgery due to cardiac septal and ductal occluder embolization between January 2007 and December 2010. Congenital defects were atrial septal defect (n = 6), ventricular septal defect (n = 1), and patent ductus arteriosus (n = 2). Risk factors for device embolization and urgent surgical management techniques for embolized device removal were discussed.ResultsRemoval of embolized devices in all cases and repair of damaged tricuspid valve in 2 patients were performed. Inevitably, all congenital defects were closed or ligated up to the primary defect. Total circulator arrest necessitated in 1 patient with ascending aortic device embolization. All operations were completed successfully and no hospital mortality or morbidity was encountered.ConclusionsAlthough closure of left to right shunting defects by percutaneous occluder devices has a lot of advantages, device embolization is still a major complication. If embolized device retrieval fails with percutaneous intervention attempts, surgical management is the only method to remove embolized devices. In this circumstance, to provide an uneventful perioperative course, urgent management strategies should be well planned.

P-wave dispersion between transcatheter and surgical closure of secundum-type atrial septal defect in childhood

Patients with atrial septal defect have an increased risk for atrial fibrillation. Increased P-wave dispersion predicts the development of atrial fibrillation. The aim of this study was to determine difference in P dispersion between transcatheter closure with Amplatzer septal occluder and surgical closure in childhood. A total of 68 children (the mean age was 7.2 plus or minus 3.3 years; the mean secundum atrial septal defects diameter was 17.3 plus or minus 5.4 millimetres) were evaluated in this study. Transcatheter closure was attempted in 41 children with secundum atrial septal defects, and the defect in 27 patients was closed by surgical techniques. P maximum, P minimum and P dispersion were measured by the 12-lead surface electrocardiography. P maximum, P minimum and P dispersion were found to be similar in patients with pre- and post-procedure (98.0 plus or minus 19.3 versus 95.1 plus or minus 23.0 milliseconds; 68.0 plus or minus 20.8 versus 67.6 plus or minus 24.3 milliseconds, 29.9 plus or minus 11.0 versus 27.1 plus or minus 12.1 milliseconds, respectively). There was no statistical significance in the comparison of P dispersion between the two groups. But in the surgical group, P-wave dispersion was decreased more significantly compared with baseline values (p-value equal to 0.03). In conclusion, there is no P dispersion between transcatheter closure with Amplatzer septal occluder and surgical closure of secundum atrial septal defect.

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.

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.

The relationship between Chlamydia pneumoniae seropositivity and peripheral vascular diseases, acute myocardial infarction and late-onset asthma.

Chlamydia pneumoniae is an obligatory intracellular pathogen. It is one of the most common causes of acute and chronic respiratory tract infections [1–3] and is associated with a wide variety of diseases including acute myocardial infarction (AMI) [4], chronic obstructive pulmonary disease (COPD) [5] and neurological complications [1, 3]. Recently, C. pneumoniae has been identified as a possible cause of prolonged acute bronchitis with wheezing [6]. Acute primary or secondary C. pneumoniae infections have been reported to initiate asthma in previously non-asthmatic individuals [5, 6]. However, the relationship between C. pneumoniae seropositivity and peripheral vascular diseases (PVD), AMI and late-onset asthma (LOA) has not been exactly defined. Serum samples were collected from inpatients of the cardiology, cardiovascular surgery and pulmonary diseases departments of Gaziantep University Hospital. The risk groups (PVD, AMI and LOA) and control group had no macrolide and tetracycline antibiotics treatment in the preceding month. Serum samples taken from both groups were analyzed [7] using a commercially available C. pneumoniae micro-immunofluorescence test (Orgenium, Finland). The first risk group consisted of 36 patients (18 female, 18 male) with PVD, diagnosed by Doppler ultrasonography. Patients in the risk group were using anti-thrombotic drugs during the collection of their serum samples. The second risk group consisted of 29 (20 male, nine female) inpatients with AMI, whose diagnosis was based on typical changes in the electrocardiogram, raised serum creatinine phosphokinase level and myocardial band isoenzyme activity. The serum samples of AMI patients were drawn within 24–36 h after the onset of symptoms and confirmation of diagnosis. All patients were smokers with hypercholesterolemia and high serum lipid levels, which were indicative of atherosclerosis. The third patient group consisted of 25 patients (10 male, 15 female) who were selected among LOA patients who were nonsmokers, non-atopic, non-wheezing and who had experienced their first asthmatic attack after the age of 40 years. These patients were only treated with bronchodilatator drugs; corticosteroids were not used. The control group was selected from 28 patients (14 male, 14 female) who had no history of organ failure (such as liver, kidney, cardiac), lung metabolic diseases or upper or lower respiratory tract infections in recent months. All of the patients were investigated for routine biochemical tests (blood sugar, urea, creatinine, cholesterol, total lipid and liver enzymes).The groups were gathered according to their age, sex, time and seropositivity to C. pneumoniae. All samples were screened at the dilution of 1 : 32 for IgG and 1 : 16 for IgA and IgM according to the manufacturer’s instructions. Samples positive for IgM and IgA were retested using an IgG inactivation reagent at titers of 1 : 20, 1 : 40, 1 : 80 and 1 : 160. C. pneumoniae seropositivity criteria were titers of 1 : 20 for IgM or IgA and 1 : 32 for IgG. The 2-test was used for statistical analysis; statistical significance was set at p < 0.05. C. pneumoniae-specific IgG antibodies were found in 73.3% of patients in the risk groups (PVD,AMI and LOA) and in 50% of their matched controls (p < 0.05). This rate was 93% in AMI patients, 66.6% in PVD and 60% in LOA patients. IgA seropositivity, considered as a possible sign of

“V-PLASTY”: a novel technique to reconstruct pulmonary valvular and annular stenosis in patients with right ventricular outflow tract obstruction

BackgroundThe goal of repair of right ventricular outflow tract obstruction with or without Tetralogy of Fallot (TOF) is to eliminate valvular and/or subvalvular obstruction. However, this operation has a high risk of late complication of pulmonary insufficiency. In this study, we aimed to present early period results of our new technique that we call “V-Plasty” developed to prevent pulmonary insufficiency after pulmonary valve reconstruction in selected patients.MethodsBetween January 2006 and January 2010, we performed V-plasty for pulmonary valve reconstruction in 10 patients. Eight patients (5 males, 3 females) had TOF and 2 patients (1 male, 1 female) had atrial septal defect concomitant with pulmonary valve stenosis. Patient selection for V-plasty reconstruction was made due to the pulmonary valve anatomy and degree of stenosis. The mean follow-up time was 55.7 ± 16.2 months (ranging from 32 to 80 months).ResultsFunctional capacity of the patients improved immediately after the surgery. There were no mortality and re-operation in follow-up period. Patients were followed up with echocardiography one week after the operation, at 1st, 6th, 12th months and annually. There was no pulmonary insufficiency.ConclusionsOperative correction of the pulmonary outflow tract obstruction with or without TOF, frequently requires transannular enlargement because of the infundibular and/or annular-valvular obstruction. This conventional technique is usually a reason for late pulmonary insufficiency. In our study, we have not seen pulmonary insufficiency in early term follow-up period. Our early term results are encouraging, but long term follow-up results are needed with large case series.