Jaffar Shehatha

Remote Ischemic Conditioning: Evolution of the Concept, Mechanisms, and Clinical Application

Abstract  Remote ischemic conditioning is a novel concept of protection against ischemia‐reperfusion injury. Brief controlled episodes of intermittent ischemia of the arm or leg may confer a powerful systemic protection against prolonged ischemia in a distant organ. This conditioning phenomenon is clinically applicable and can be performed before—preconditioning, during—perconditioning, or after—postconditioning prolonged distant organ ischemia. The remote ischemic conditioning may have an immense impact on clinical practice in the near future. (J Card Surg 2010;25:127‐134)

Thoracic Hydatid Disease; A Review of 763 Cases

BACKGROUND Thoracic hydatid disease remains a significant health problem in endemic areas. The aim of this study was to retrospectively evaluate 763 patients diagnosed with thoracic hydatid cysts and treated surgically at Ibn-Alnafis Teaching Hospital between January 1986 and January 2006. METHODS All patients underwent surgery. The mean age was 26 years. Intact cysts were enucleated in 468 patients after injection with a scolicidal agent and the remaining cavity was left open after securing localised air leaks. Pulmonary resections were performed in 198 patients. RESULTS Most cysts were removed without lung resection. Resection was reserved for large cysts, severe suppuration and complicated cases with haemoptysis or bronchiectasis. However, lung preservation was always attempted initially. In patients with intact lung cysts, 37% were asymptomatic with incidental diagnosis on routine chest X-ray. Mortality was 1% and morbidity was 12.6%. CONCLUSION Lung preservation without obliteration of pericystic cavity provides good result in patients with uncomplicated hydatid cysts. Radical resection should be reserved for complicated cases. Medical treatment is indicated postoperatively especially for recurrent or multiple hydatid cysts.

Remote ischemic preconditioning stimulus decreases the expression of kinin receptors in human neutrophils

BACKGROUND Remote ischemic preconditioning (RIPC) has been shown to reduce ischemic-reperfusion injury and is induced by brief forearm ischemia. Kinins are known to be involved in RIPC and act via the G protein coupled B1 and B2 receptors. Interaction of the kinins with their respective receptors causes receptor internalization, thereby reducing the potential for further activation. This may be critical for the protective effect of RIPC and if so, we hypothesized, would significantly decrease the expression of kinin receptors on the surface of neutrophils. METHODS The study was performed on five healthy human volunteers. The left forearm was rendered ischemic for three 5-min periods, each separated by 5 min of reperfusion. Three venous blood samples were taken from the right arm, one before and two after RIPC. Neutrophil isolation, immunofluorescence labeling, and confocal microscopy were performed. Mean pixel intensity data were generated using a fixed circular area of interest (AOI, 40×40 μm). For every image, the AOI was placed over a cell and the mean pixel intensity was recorded. The mean intensity was expressed as pixel×10(2)/μm(2) and presented as mean±SEM. Immunofluorescence at the different time points was compared by one way analysis of variance with Bonferronis post-hoc test. A P value<0.05 was considered significant. RESULTS The mean pixel intensity for kinin B1 receptors was decreased at 24 h after RIPC compared with both baseline and 15 min after RIPC (P<0.001). Similarly, the intensity for B2 receptor labeling on neutrophils was significantly decreased 24 h after RIPC compared with the baseline value (P<0.001). CONCLUSIONS RIPC decreases expression of kinin receptors on circulating human neutrophils. Reduction in kinin surface receptors suggests internalization of receptors and is consistent with the concepts of kinin receptor activation and their role in RIPC.

The role of esophageal stent placement in the management of postesophagectomy anastomotic leak.

Background/Aim: Anastomotic leak after esophagectomy is one of the most challenging complications resulting in a high morbidity and mortality and prolonged hospitalization. The study intended to assess the outcome of endoluminal self-expanding stent in the treatment of this problem. Settings and Design: Department of Thoracic and Cardiovascular Surgery, Arhus University Hospital, Skejby, Arhus, Denmark. A retrospective study. Patients and Methods: From January 2007 to December 2010, 209 patients underwent esophagectomy for malignant disease of the esophagus or the cardia. Twenty patients developed anastomotic leak. Treatment consisted of conservative measures, surgery, and stent placement. Details of treatment, clinical outcome, complications, and mortality were evaluated. Statistical analysis: None. Results: One hundred and forty-seven patients (70.3%) had carcinoma of the cardia, whereas 62 patients (29.7%) had esophageal carcinoma. Twenty patients (9.5%) developed anastomotic leak; small (<1 cm) in two patients (10%); managed conservatively and bigger than 1 cm in 15 patients (75%); treated with an esophageal stent (Hanaro stent, DIAGMED Healthcare, Thirsk, YO7 3TD, United Kingdom). In three patients (15%), perforation of the staple line of the intrathoracic gastric conduit was found and managed by reoperation. Functional sealing of anastomoses after stent placement could be achieved in 10 patients (67%). Stent-related morbidity developed in five patients (33%): Migration of the stent, n=3 and tracheoesophageal fistula, n=2. Stents were smoothly removed 3 weeks after discharge. The mean hospital stay was 25 days. There was only one stent-related death (6.6%). Conclusion: Endoluminal stent implantation is an effective and safe option in the management of postesophagectomy leaks.

Surgical management of extensive pulmonary artery sarcoma.

Primary pulmonary artery sarcoma is a rare tumor that can be misdiagnosed as acute or chronic pulmonary thromboembolic disease. This article reports a patient with a preoperative diagnosis of pulmonary embolism who was found to have an extensive pulmonary artery tumor. Surgical resection of the primary pulmonary artery sarcoma and reconstruction of the central pulmonary arteries, followed by adjuvant chemoradiotherapy, provided significant improvement in his clinical symptoms.

Role of Extracorporeal Circulation in the Management of Accidental Deep Hypothermia

Deep hypothermia leading to cardiac arrest requires aggressive management for resuscitation. Various methods are available to rewarm the patient. We hereby present a case report where active resuscitation was carried out using cardiopulmonary bypass in a young female who was found unconscious with a core temperature of 26 degrees C. The relevant literature is also reviewed.

Novel Aeration Technique for Necrotizing Fasciitis of the Chest Wall

Necrotizing fasciitis of the chest wall is rare and associated with high mortality. Herein we present a patient with necrotizing fasciitis who was managed successfully with aggressive surgical debridement combined with an aeration system that provided effective aeration and drainage of the infected tissues.

Coronary artery bypass in a patient with single anomalous right coronary artery.

The true incidence of coronary artery anomalies in the general population is unknown. Rarely, atherosclerotic coronary artery disease can be associated with single coronary artery. We describe coronary artery bypass surgery in a 57-year-old man with this association.

Coronary stent disease: When will enough be enough?

CLINICAL SUMMARY A 60-year-old man was transferred to the Sir Charles Gairdner Hospital with unstable angina. His comorbidities were obesity (body mass index 33.6 kg/m), hypertension, type II diabetes mellitus requiring insulin, hypercholesterolemia, and chronic renal failure (creatinine 150 mmol/L) due to diabetic nephropathy. The patient was an ex-smoker. Left ventricular ejection fraction was 45% with hypokinesis of the inferolateral wall. He had severely diseased left anterior descending (LAD) and left circumflex (LCx) coronary arteries with multiple in-stent stenoses (Figure 1) and a small nondominant right coronary artery. The patient had been previously managed elsewhere. In March of 2002, he was admitted with unstable angina and underwent percutaneous transluminal coronary angioplasty (PTCA) of the obtuse marginal (OM) branch. During angioplasty, the OM branch was dissected. A 2.5-mm Tsunami stent (Terumo Corporation, Tokyo, Japan) and a 2.5-mm Pixel stent (Guidant, Santa Clara, Calif) were placed to overlap the area of dissection. In October of 2002, unstable angina and in-stent stenosis of the OM developed, which were managed by PTCA alone. In May of 2003, unstable angina recurred. The patient underwent repeat PTCA to the LAD and LCx arteries, during which 3 Cypher stents (Cordis Corporation, Warren, NJ) were placed in the proximal LAD occluding the second diagonal branch and 4 Zeta stents (Abbott Laboratories, Abbott Park, Ill) were placed in the LCx. In January of 2007, the patient presented with unstable angina, inferolateral myocardial infarction, and pulmonary edema. The in-stent stenosis in the distal LCx was demonstrated, and the flow was restored with 4 Cypher stents. In March of 2007, he presented again with a prolonged episode of angina and inferolateral infarction and was found to have

Early-onset Streptomyces endocarditis in a prosthetic aortic valve.

A 66-year-old Australian man underwent elective replacement of a severely stenotic aortic valve with a 22-mm Medtronic-Hall valve. Six weeks later, he was readmitted with worsening dyspnea, fever, and mild anemia. Investigations confirmed pulmonary edema and moderate periprosthetic aortic regurgitation. The pulmonary edema was managed conservatively, and a second 22-mm Medtronic-Hall valve was implanted. Infective endocarditis was suspected in the aortic annulus below the orifice of the right coronary artery. A bacteriological study revealed a rare bacteria of Streptomyces species. The patient received intensive antibiotic therapy over a 6-week period of hospitalization, and the aortic regurgitation disappeared one week postoperatively.