Mehmet Bademci

Delayed sternal closure: an effective procedure for life-saving in open-heart surgery.

OBJECTIVE To determine the incidence, short term survival and safety of delayed sternal closure following open-heart operation due to myocardial edema, non-surgical bleeding and malignant arrhythmia. METHODS We retrospectively reviewed our medical records to identify the patients who underwent delayed sternal closure following open-heart operation and recorded morbidity, mortality postoperative complications of these patients. Among 2698 patients who underwent on- pump cardiac surgery, the sternum was left open in 46 (1.7%) patients, 31 men and 15 women, ranging in age from 2 to 73 years (mean 57.0+/-7.6 years). In 39 patients sternum was left opened following the initial operation and in 7 patients sternum was re-opened due to bleeding or hemodynamic instability after initial surgery. Statistical analysis was accomplished using Chi-square test, Mann Whitney U test and analysis of variances for repeated measurements. RESULTS The operative procedures were classified as elective in 24 (52.8%), emergency in 10 (22%), urgent in 7 (15.4%), and redo cardiac operations in 5 patients (11%). Bleeding (n=21), hemodynamic instability (n=16), arrest (n=5), and arrhythmia (n=4) were the reasons of delayed sternal closure. The patients had an open sternum for 3.48+/-0.35 days. Time to discharge was 21.5+/-1.6 days after operation and 17.6+/-1.6 days after sternal closure. Mortality within 30 days was 23.9% (7 patients died before closure and the remaining 4 after closure). Complications were mediastinitis (n=2), minor wound infection (n=3) and renal failure (n=5). CONCLUSION Delayed sternal closure is a safe and simple method for treating bleeding, arrhythmia and myocardial edema following on pump cardiac surgery. It is anticipated that as cardiac surgeons become more familiar with the technique of delayed sternal closure, the frequency of its use following on pump cardiac surgery may increase.

Assessment of protective effects of methylprednisolone and pheniramine maleate on reperfusion injury in kidney after distant organ ischemia: a rat model.

BACKGROUND Ischemia/reperfusion (I/R) injury of tissues is a common problem that cardiovascular surgeons are faced with. Suppression of inflammation, which plays an important role in the pathogenesis of I/R injury, may reduce this damage. The aim of this study is to investigate the protective effects of methylprednisolone (MP)--a potent anti-inflammatory agent--and pheniramine maleate (FM)--an antihistamine that also has some anti-inflammatory effects--on reperfusion injury of kidneys developing after ischemia of the left lower extremity of rats. METHODS Twenty-eight randomly selected male Sprague-Dawley rats weighing 320 to 370 g were divided into four groups, each consisting of seven rats. Group 1 was the control group. Group 2 was the sham group. Rats in group 3 were subjected to I/R and given FM, and rats in group 4 were subjected to I/R and given MP. A tourniquet was applied at the level of the left groin to subjects in group 2 after induction of anesthesia. One hour of ischemia was performed, and no drug was administered. In group 3, half of a total dose of 10 mg/kg FM was administered before ischemia, and the remaining half was given intraperitoneally before reperfusion. In group 4, subjects received a single dose of 50 mg/kg MP intraperitoneally in the 30th minute of ischemia. Kidneys of all subjects were removed after 24 hours. Extracted tissues were investigated regarding histological and biochemical parameters. RESULTS Malondialdehyde--the end product of lipid peroxidation as an important indicator of I/R injury--levels were significantly lower in group 3 than in group 2 (P < 0.05). Malondialdehyde levels were also lower in group 4 than in group 2, but this difference was insignificant (P > 0.05). Superoxide dismutase and glutathione peroxidase enzyme activities were found to be significantly higher in group 3 than in group 2 (P < 0.05). However, there was no difference between group 4 and group 2 in terms of these activities. Histological examination demonstrated that both MP and FM had protective effects against I/R injury, but this effect was more potent for FM than for MP. CONCLUSIONS FM has a protective effect against reperfusion injury in rat kidney after distant organ ischemia.

Surgical stimulation of angiogenesis

Objective The results of surgical approaches are unsatisfactory in patients with a distal arterial bed that is ineligible for revascularization. In this retrospective study, we investigated outcomes in patients who underwent surgical interventions that are reported to induce angiogenesis. Method 6 patients diagnosed with thromboangiitis obliterans were included in this study. Of these 6 patients, 2 underwent femoropopliteal bypass surgery using reversed great saphenous vein as a conduit. The other 4 underwent ascending venous arterialization (bypass from the popliteal artery to the great saphenous vein at the level of medial malleolus, using reversed great saphenous vein). Results During the early postoperative period, all of the reversed saphenous vein grafts were occluded. The mean postoperative ankle-brachial index increased from 0.33 to 0.83. During the postoperative period, intermittent claudication disappeared in all patients. Angiograms taken during the postoperative period showed evidence of neovascularization when compared to those taken during preoperative evaluation. Conclusion Wound healing is an inflammatory process that simultaneously activates angiogenesis. We propose that the improved ankle-brachial index values and neovascularization shown in our patients were associated with this inflammatory process.

α-tocopherol and ascorbic acid in early postoperative period of cardiopulmonary bypass

Aim To investigate whether &agr;-tocopherol and ascorbic acid have effect on the suppression of inflammation in the early postoperative period after open heart surgery. Methods A total of 59 patients who had undergone cardiopulmonary bypass (CPB) in the Cardiovascular Surgery Department of a tertiary center between June 2008 and December 2008 were retrospectively investigated. The study group consisted of 34 patients (25 men, 9 women) to whom ascorbic acid (500 mg/day) and &agr;-tocopherol (300 mg/day) were administered on the day of operation (0th day) and the first four consecutive postoperative days. In contrast, 25 controls (20 men, 5 women) received no additional anti-inflammatory medications. The two groups were compared in terms of demographics, blood parameters such as C-reactive protein (CRP) and white blood cell (WBC) count, and durations of cross-clamp and CPB. Results In the control group, CRP levels were found to be increased on the first postoperative day (P < 0.001) and CRP levels were correlated with triglyceride levels on the day of operation (P = 0.009) and the first postoperative day (P = 0.021). On the second postoperative day WBC count was found to be decreased (P = 0.008) and correlated with glucose level (P < 0.005). In the study group, CRP levels were found to be inversely correlated with serum high-density lipoprotein (HDL) (P = 0.049) on the first postoperative day and directly correlated with triglyceride levels on the second postoperative day (P = 0.017). Blood glucose levels were found to be increased on the first postoperative day (P = 0.021) and a correlation was detected between WBC count on the fourth postoperative day and doses of ascorbic acid and &agr;-tocopherol (P = 0.027). Conclusion Suppression of the systemic inflammatory response to CPB is a double-edged sword and whether this suppression aids in the attenuation of morbidity and mortality is obscure. In this respect, ascorbic acid and &agr;-tocopherol seem to display some anti-inflammatory effect, but further studies are necessary to reveal the actual therapeutic potential and the complex mechanism related to biochemical and inflammatory parameters.

Effect of 1α-25-dihydroxyvitamin D3 on intimal hyperplasia developing in vascular anastomoses: a rabbit model

Introduction A common problem encountered in routine daily practice of cardiovascular surgery is migration of smooth muscle cells leading to intimal hyperplasia developing at vascular anastomosis sites which then causes luminal narrowing. The aim of this study was to investigate the antiproliferative effect of 1,25 (OH)2D3 on intimal hyperplasia. Material and methods Twenty-one male white New Zealand rabbits weighing 2-3 kg were selected. There were 3 groups of animals each consisting of 7 rabbits. Group 1 was the control group. Group 2 was the sham group and group 3 consisted of rabbits receiving 1,25 (OH)2D3. The right carotid arteries of the subjects in groups 2 and 3 were transected and re-anastomosed. A daily dose of 25 ng 1,25 (OH)2D3 per 100 g body weight was administered for 14 days to rabbits in group 3. Rabbits in group 2 were not subject to any pharmaceutical agent. All the subjects were sacrificed at the end of the 28th postoperative day. Their right carotid arteries were resected and then investigated histopathologically. Results Intimal thickness and intimal area were measured as significantly lower in group 1 when compared with the other groups (p = 0.004). In group 3, the ratios of thickness of tunica intima/thickness of tunica media and area of tunica intima/area of tunica media were significantly lower than those of group 2 (p = 0.015, p = 0.003). Conclusions 1,25 (OH)2D3, the active metabolite of vitamin D, reduces the intimal hyperplasia developing after vascular anastomoses.

A new percutaneous technique: N-butyl cyanoacrylate adhesive for the treatment of giant saphenous vein insufficiency

Background We have made a retrospective evaluation of the results of the cyanoacrylate ablation technique which has recently started to be used in the treatment of giant saphenous vein insufficiency today and in which tumescent anesthesia is not required. Methods Giant saphenous vein was treated in 50 patients between September 2015 and September 2016 by using endovenous cyanoacrylate ablation. In the procedure, tumescent anesthesia and varsity socks were not used. Control duplex ultrasound evaluation was performed in the post-procedural 1st, 6th and 12th months. Venous Clinical Severity Score and Aberdeen Varicose Vein Questionnaire scores were evaluated. Results In the 50 patients who were treated, full closure was observed in giant saphenous vein in 47 (94%) patients in the 12th month control duplex ultrasound. The mean age of the patients was 46.4 (20–70) and 30 (60%) of them were female. The median Venous Clinical Severity Score scores in the 1st, 6th and 12th months were 3, 2 and 1, respectively (p < 0.001); the median Aberdeen Varicose Vein Questionnaire scores in the 1st, 6th and 12th months were 7, 5 and 4, respectively (p < 0.001). In the access site, two (4%) patients developed phlebitis and one (2%) developed ecchymosis. However, deep venous thrombosis, pulmonary embolism and paresthesia were not observed. Conclusion Considering the early period results in the treatment of giant saphenous vein insufficiency, cyanoacrylate ablation makes a more reliable alternative than endovenous thermal ablation methods in that it does not require tumescent anesthesia and it has a low incidence of adverse effects.

Is the cause of death in hypertrophic cardiomyopathy low pressure gradient in left ventricular outflow

References 1. Holzhey DM, Schuler G, Mohr FW, Mukherjee C. Transapical double valve implantation plus percutaneous revascularization as a bailout for a highrisk patient. J Thorac Cardiovasc Surg. 2012;144: 508-10. 2. Cheung AW, Gurvitch R, Ye J, Wood D, Lichtenstein SV, Thompson C, et al. Transcatheter transapical mitral valve-in-valve implantations for a failed bioprosthesis: a case series. J Thorac Cardiovasc Surg. 2011;141:711-5. 3. Carpentier A, Adams DH, Filsoufi F. Techniques in type I dysfunction. In: Carpentier A, Adams DH, Filsoufi F, eds. Carpentier’s reconstructive valve surgery from valve analysis to valve reconstruction. St Louis: Saunders–Elsevier; 2010:65.

Thrombolytic Treatment of Pulmonary Embolism Via Catheter

1. Kim JT, Chang WH, Oh TY, Jeong YK. Venous distensibility as a key factor in the success of arteriovenous fistulas at the wrist. Ann Vasc Surg 2011;25:1094e8. 2. Malovrh M. Native arteriovenous fistula: preoperative evaluation. Am J Kidney Dis 2002;39:1218e25. 3. Radovic M, Jemcov T. Primary arteriovenous fistula patency is dependent on venous distensibility, not on proinflammatory, procoagulant markers or vascular functional parameters. J Am Soc Nephrol 2011. 22(SA-OR455):109A. ASN Kidney Week 2011-Meeting Abstract.

Ultrasound-Guided Superficialization of an Arteriovenous Fistula by Minimally Invasive Liposuction Technique: Letters to the Editor

Dear Editor, Arteriovenous fistula (AVF) is commonly performed and is the preferred vascular access type for hemodialysis treatment. Fistulas should be located superficially enough to allow repeated safe cannulation. Superficialization of the vein is often necessary in obese patients or those with deep veins. Multiple techniques have been described for superficialization of the fistulas, minimally invasive ultrasound-guided liposuction is one of the promising methods with shorter recovery and theoretically improved patency rates (1). Thus, this technique may be a possible alternative to traditional surgical superficialization procedures. We presented a case of a 68-year-old female patient (obese, BMI: 43.4 kg/m) with a right-sided brachiocephalic AVF created 7 weeks previously and matured properly (6.5 mm diameter and 850 mL/min flow) but cannulation was not achieved due to its deep location. The subcutaneous fat thickness varied from 8 to 12 mm at the upper arm and a minimally invasive ultrasound-guided liposuction technique was planned. The course of the cephalic vein was marked with ultrasound guidance. Under conscious sedation, local tumescent solution was used above the cephalic vein for an 18 × 2 cm area under ultrasound guidance. A stab incision was made 1 cm above the anticubital fossa and the overlying subcutaneous fat was aspirated in radial fashion above the vein with 4and 5-mm Coleman aspiration cannulas (Byron Inc., Tucson, AZ, USA) under continuous ultrasound monitoring (Figs 1–2). The subcutaneous adipose tissue was thinned and visible pulsations were felt by hand after 150 mL of lipoaspirate. A completion ultrasound was performed and no extravasation or injury was noted. The arm wrapped in a slight pressure bandage. The fistula had adequate superficialization at the third week postoperatively and was successfully accessed with two needles. Traditionally, elevation and tunneled transposition technique is the most commonly used formal FIG. 1. A stab incision was made 1 cm above the anticubital fossa. [Colour figure can be viewed at wileyonlinelibrary.com]

Postoperative cognitive dysfunction markers in coronary artery surgery.

We congratulate Özturk et al. (1) on their study entitled “Effect of the type of cardiopulmonary bypass pump flow on postoperative cognitive function in patients undergoing isolated coronary artery surgery” published for the Anatolian Journal of Cardiology 2016 May 9 as an Epub ahead of print. We believe that we can offer the authors some points that will contribute to their study in which they compared use of pulsatile and non-pulsatile pumps in terms of post-operative cognitive dysfunction (POCD). Firstly, although the study is prospective, not very many data about the patients were analyzed. Some factors that are predictors of POCD should have been compared between the 2 groups. For example, we see that the authors did not analyze hypertension, diabetes mellitus, duration of operation, period of anesthesia, preoperative low ejection fraction, low effort capacity, or preoperative European system for cardiac operative risk evaluation levels, which are described as predictor factors for POCD in several studies (2, 3). In order to compare the 2 groups, it should have been reported that there was no difference on the basis of these parameters. The authors, inspired by some previous studies, analyzed levels of S100β and neuron-specific enclose biomarkers, which they thought might be associated with POCD. However, one of the most-used biomarkers in the literature associated with POCD is serum cortisone level (4). We are of the opinion that if the authors provide us with their ideas on this subject and if they can share any available data for these parameters, it will surely add value to their study.