Ibrahim Goksin

Systemic and local antibiotic prophylaxis in the prevention of Staphylococcus epidermidis graft infection

BackgroundThe aim of the study was to investigate the in vivo efficacy of local and systemic antibiotic prophylaxis in the prevention of Staphylococcus (S.) epidermidis graft infection in a rat model and to evaluate the bacterial adherence to frequently used prosthetic graft materials.MethodsGraft infections were established in the subcutaneous tissue of 120 male Wistar rats by implantation of Dacron/ePTFE grafts followed by topical inoculation with 2 × 107 CFUs of clinical isolate of methicillin-resistant S. epidermidis. Each of the graft series included a control group, one contaminated group that did not receive any antibiotic prophylaxis, two contaminated groups that received systemic prophylaxis with teicoplanin or levofloxacin and two contaminated groups that received teicoplanin-soaked or levofloxacin-soaked grafts. The grafts were removed 7 days after implantation and evaluated by quantitative culture.ResultsThere was significant bacterial growth inhibition in the groups given systemic or local prophylaxis (P < 0.05). Methicillin-resistant S. epidermidis had greater affinity to Dacron graft when compared with ePTFE graft in the untreated contaminated groups (P < 0.05).ConclusionThe study demonstrated that the usage of systemic or local prophylaxis and preference of ePTFE graft can be useful in reducing the risk of vascular graft infections caused by staphylococcal strains with high levels of resistance.

Preservation of pleural integrity in patients undergoing coronary artery bypass grafting: effect on postoperative bleeding and respiratory function.

Objective —The purpose of this study was to evaluate the influence of preserved integrity of pleura on postoperative bleeding and respiratory function in patients undergoing coronary artery bypass grafting (CABG). Methods and results — Seventy-two CABG patients who received pedunculated IMA graft without opening the pleura (group of intact pleura, group IP) between July 2002 and September 2004 were matched to 72 CABG patients who received pedunculated IMA graft with opened pleura (group of opened pleura, group OP).To match the patients with IP and unique patients with OP, logistic regression was used to develop a propensity score. The C statistic for this model was 0.79. Patients with IP were matched to unique patients with OP with an identical 5-digit propensity score. If this could not be done, we proceeded to a 4-, 3-, 2-, or 1-digit match. Patients characteristics were well matched. There were no differences in preoperative and peroperative variables between the groups. The incidence of postoperative pleural effusion and thoracentesis were significantly lower in group IP than group OP (pleural effusion in 15.2 versus 30.5%; p = 0.029, thoracentesis in 5.5 versus 18.5%; p = 0.036). Other pulmonary complications such as prolonged ventilation, reintubation, pneumothorax, atelectasis, diaphragmatic paralysis were similar in both groups. Patients with IP had significantly lower blood loss (520 versus 870 ml; p < 0.001) and whole blood unit transfusion (26.3 versus 41.6%, p = 0.036). Also, intensive care unit and hospital stay were similar in both groups. Conclusions — Meticulous internal mammary artery harvesting and preservation of the pleural integrity significantly reduces postoperative bleeding and pleural effusion.

Mannitol attenuates acute lung injury induced by infrarenal aortic occlusion-reperfusion in rats

PurposeMannitol is used as a treatment for ischemia/reperfusion (IR) injury of various organs in humans, despite the fact that its effectiveness in vivo is still disputed. The purpose of this study was to determine the effects of mannitol on acute lung injury (ALI) induced by infrarenal aortic occlusion.MethodsMale Wistar-albino rats were allocated into five groups: (i) sham-operated group, which received a laparotomy without IR injury (n = 12); (ii) IR group, which received 3 h of ischemia followed by 2 h of reperfusion (n = 12); (iii) IR + inferior caval phlebotomy (ICP) group, which was identical to group 2 except for 1 ml of blood aspiration from the inferior caval vein (n = 12); (iv) IR + mannitol-treated group, for which rats were subjected to IR and received a bolus injection of mannitol (n = 12); and (v) IR + ICP + mannitol-treated group, which underwent the same procedures as described for the previous groups. Arterial blood gas parameters were studied and bronchoalveolar lavage (BAL) was performed. Evans blue dye was injected into half of the rats. We biochemically assessed the degree of pulmonary tissue injury by investigating oxidative stress markers and enzymatic and nonenzymatic antioxidant markers, and evaluated ALI by establishing pulmonary leukosequestration and ALI scoring, histopathologically. Pulmonary edema was estimated by using Evans blue dye extravasation and wet/dry weight ratios.ResultsHypertonic mannitol treatment significantly reduced oxidative stress markers, and significantly increased enzymatic and nonenzymatic antioxidant markers in the lung tissues (P < 0.05). Arterial blood gas parameters were significantly ameliorated (P < 0.05), the BAL cytology was significantly better (P < 0.05), pulmonary leukosequestration and ALI scores were significantly decreased (P < 0.05), and pulmonary edema was significantly alleviated (P < 0.05) by mannitol administration.ConclusionThis study clearly showed that mannitol treatment significantly attenuated the aortic IR-induced ALI. Further clinical studies are required to clarify whether mannitol has a useful role in ALI during surgeries in which IR-induced organ injury occurs.

Coronary Arterial Revascularization in an Adult with Congenitally Corrected Transposition of Great Arteries and Dextrocardia

Abstract  Objectives:Congenitally corrected transposition of great arteries with dextrocardia is an extremely rare lesion in adulthood. This group of patients does not live long enough for atherosclerotic coronary artery disease processes, because of existing comorbid anomalies. Methods: We report a 47‐year‐old man with isolated congenitally corrected transposition of great arteries, dextrocardia, and athersclerotic coronary artery disease. The patient underwent coronary artery revascularization with cardiopulmonary bypass. The free left internal mammary artery (LIMA) was grafted to the tiny left anterior descending artery (LAD), and the reversed saphenous vein Y graft was anastomosed to the posterior descending and posterolateral branches of the morphologic right coronary artery. Results: The patient recovered uneventfully. He is alive and well 24 months after the surgery. Conclusions: To our knowledge, the present case is the first congenitally corrected transposition of great arteries with dextrocardia treated with grafted coronary artery bypass. Early and full revascularization is very important for the systemic right ventricle exposed to a systemic workload. The vessel pathologies and technical details of this unusual case are discussed in this paper.

Surgical treatment of cardiogenic shock due to huge right atrial thromboembolus.

An unusual case is reported of thromboembolus in the right atrium associated with cardiogenic shock and multiple pulmonary micro-embolisms. Two-dimensional echocardiograpy demonstrated a large irregular mass in the right atrium floating freely, prolapsing through the tricuspid valve into the right ventricle during diastole, and leading to inflow and outflow obstruction. An emergency operation was performed and the thromboembolic material was successfully extracted from the right atrium without using cardiopulmonary bypass. This exemplary case highlights the benefit of surgical intervention rather than more conservative approaches such as anticoagulation and/or thrombolysis.

Exploring strategies to prevent post-lobectomy space: transient diaphragmatic paralysis using Botulinum Toxin Type A (BTX-A)

ObjectiveVarious techniques to reduce air space after pulmonary lobectomy especially for lung cancer have been an important concern in thoracic surgical practice. The aim of this study was to assess the effectiveness of Botulinum toxin A (BTX-A) injection into the diaphragm to reduce air space after right lower pulmonary lobectomy in an animal model.MethodsTwelve male New Zealand rabbits were randomly allocated into two groups. All animals underwent right lower lobectomy. Then, normal saline of 0,1 ml and 10 units of 0,1 ml Botulinum toxin type A were injected into the muscular part of the right hemidiaphragm in control (n = 6) and BTX-A groups (n = 6) respectively. Residual air space and diaphragmatic elevation were evaluated with chest X-ray pre- and postoperatively. Diaphragmatic elevation was measured as a distance in millimetre from the line connecting the 10th ribs to the midpoint of the right hemidiaphragm.ResultsThe mean diaphragmatic elevation in BTX-A and control groups were 7.0 ± 2.5 and 1.3 ± 1.2 millimetres respectively. Diaphragmatic elevations were significantly higher in BTX-A group (p = 0.0035).ConclusionIntraoperative Botulinum toxin type A injection may reduce postlobectomy spaces effectively via hemidiaphragmatic paralysis in rabbits. Further studies are needed to validate the safe use of Botulinum toxin type A in human beings.

Neuraminidase produces a decrease of adherence of slime-forming Staphylococcus aureus to gelatin-impregnated polyester fiber graft fabric: an experimental study.

Because slime-forming microorganisms are the major causative agents of graft infections, we aimed to investigate bacterial adherence in slime-forming and nonslime-forming Staphylococcus aureus and to determine the role of neuraminidase (NANase) on adherence to gelatin-impregnated polyester fiber graft fabric. An in vitro model was developed to quantitatively measure bacterial adherence to the surface of the graft. The grafts were divided into two groups – those colonized with slime-forming S. aureus and those colonized with nonslime-forming S. aureus. The grafts were put into sterile tubes and human plasma was instilled and incubated at 37°C to perform fibrin deposition on the grafts. After 48 h of incubation, grafts were drained and inoculated with slime-forming or nonslime-forming S. aureus in triptic soy broth in the presence or absence of NANase. Following 36 h of incubation at 36°C, grafts were vortexed and cultured to perform a colony count. Bacterial counts were expressed as total colony-forming units per square centimeter of graft. Slime-forming S. aureus had greater affinity with the graft compared with nonslime-forming S. aureus (P < 0.05). The adherence of slime-forming S. aureus was impaired by NANase treatment (P < 0.001) but NANase treatment of nonslime-forming S. aureus did not change the adherence to the graft (P > 0.05). These results show that slime plays an important role in the pathogenesis of vascular graft infection. Adherence of slime-forming S. aureus can be decreased by NANase treatment. This may have implications for the development of neuraminidase-embedded vascular grafts to diminish biomaterial-related infections.

Evaluating Coronary–Cameral Fistulas

To the Editor: Having read the interesting case report by Banerjee and Patra1 in the August 2016 issue of the Journal, we wish to contribute to their discussion on coronary–cameral fistulas (CCFs). Acquired CCFs may be iatrogenic or post-traumatic. For a CCF to be classified as acquired, it must not have been present at birth, it must not have been seen on prior angiographic images, and its cause must be known. Potential causes are previous myocardial infarction; a diagnostic or interventional endovascular procedure, such as percutaneous transluminal coronary angioplasty or stenting; aortic or mitral valve surgery; coronary artery bypass grafting; congenital heart surgery for tetralogy of Fallot, ventricular septal defect (VSD), double-chambered right ventricle, or transposition of the great arteries with VSD; septal myectomy in the treatment of hypertrophic cardiomyopathy; chest trauma; permanent pacemaker implantation; and complications after endomyocardial biopsy.2,3 Although most CCFs are asymptomatic, the size of the fistula and severity of the left–right shunt might cause symptoms. Clinical findings include a continuous cardiac murmur; difficulty breathing; exertional dyspnea; high-flow heart failure caused by the left–right shunt (except when fistulas open to the left ventricle [LV]); pulmonary hypertension; cardiac arrhythmias; stroke; endocarditis; chest pain or myocardial infarction caused by coronary steal; cardiac tamponade from fistula aneurysm, dissection, or rupture; and sudden cardiac death.2-4 Because the left–right shunt fraction can be restricted by high intracavitary pressure, substantial hemodynamic changes might not be observed when CCFs open to the LV. However, ischemic chest pain or myocardial infarction might develop in these patients because of coronary steal.4

30-year patency of a saphenous vein graft in coronary bypass graft surgery.

3 74-year-old man was admitted to our institute complaining of angina pectoris. Electrocardiograhy revealed sinus rhythm with left bundle branch block. e had a 30-year history of acetylsalicylic acid use. Thirty years previously, an anastomosis had been created etween the ascending aorta and the left anterior descendng artery (LAD) using a saphenous vein graft. Angiograhy showed significant lesions in the right coronary and ircumflex coronary arteries. The proximal LAD artery was ompletely occluded, but the previously performed aortoAD bypass was working perfectly (Fig 1A, Angiographic mage; B, diameters of vessels. 1 saphenous vein graft; 2 the proximal LAD; 3 the distal LAD; 4 6F Judkins atheter; * proximal anastomosis; ** distal anastomois). The right coronary artery and circumflex lesions were uccessfully treated with stents. The best predictor of the graft patency is the diameter f the vessel. For saphenous vein grafts performed to the AD, the 10-year patency is 90% for vessels exceeding 2.0