Mehmet Besir Akpinar

Alpha lipoic acid attenuates inflammatory response during extracorporeal circulation

Aim Extracorporeal circulation (ECC) of blood during cardiopulmonary surgery has been shown to stimulate various pro-inflammatory molecules such as cytokines and chemokines. The biochemical oxidation/reduction pathways of a-lipoic acid suggest that it may have antioxidant properties. Methods In this study we aimed to evaluate only patients with coronary heart disease and those planned for coronary artery bypass graft operation. Blood samples were obtained from the patients before the operation (P1) and one (P2), four (P3), 24 (P4) and 48 hours (P5) after administration of a-lipoic acid (LA). The patients were divided into two groups, control and LA treatment group. Levels of interleukin-6 (IL-6) and -8 (IL-8), complement 3 (C3) and 4 (C4), anti-streptolysin (ASO), C-reactive protein (CRP) and haptoglobin were assessed in the blood samples. Results Cytokine IL-6 and IL-8 levels were significantly higher after surgery. Compared with the control groups, LA significantly decreased IL-6 and IL-8 levels in a time-dependent manner. CRP levels did not show significant variation in the first three time periods. CRP levels were higher after surgery, especially in the later periods. These results demonstrate that CRP formation depends on cytokine release. C3 and C4 levels were significantly higher after surgery than in the pre-operative period. LA treatment decreased C3 and C4 levels. Therefore, LA administration may be useful for the treatment of diseases and processes where excessive cytokine release could cause oxidative damage. Conclusions Our findings suggest a possible benefit of using LA during cardiac surgery to reduce cytokine levels.

Dilatation of the Virchow-Robin spaces as an indicator of unilateral carotid artery stenosis: correlation with white matter lesions

Background Virchow-Robin space (VRS) dilatation is related to many pathologic conditions, mostly associated with vascular abnormalities. White matter lesions (WMLs) are commonly seen on brain magnetic resonance imaging (MRI) with advancing age and generally considered as potential markers for vascular disease. Purpose To investigate if asymmetric dilatation of VRSs and WMLs are associated with unilateral internal carotid artery stenosis (ICAS) and to test the relationship between dilated VRSs and common vascular risk factors. Material and Methods Twenty-nine patients (18 men, 11 women; mean age, 68.62 years) with unilateral ICAS (≥70% carotid stenosis) undergoing carotid endarterectomy were identified for this Health Insurance Portability and Accountability Act (HIPAA) compliant prospective study and assessed with brain MRI. Two experienced radiologists scored VRSs and WMLs and evaluated old infarcts, chronic lacunar infarcts, and cerebral atrophy. Asymmetry of WML and VRS scores between two cerebral hemispheres was assessed and associations between VRS scores, WML scores, and explanatory variables (e.g. age, sex, vascular risk factors, and atrophy) were tested. Results In this study, WMLs and basal ganglia VRSs were significantly greater in the unilateral hemisphere with ICA stenosis than contralateral hemisphere. Basal ganglia VRSs were associated with WMLs and internal cerebral atrophy. No association between the severity of VRSs and vascular risk factors was found. Conclusion ICA stenosis may contribute as a factor in the development of WMLs and dilatation of VRSs by causing chronic hypoperfusion. VRS dilatation may be an additional MRI marker of ICAS.

Ankaferd Blood Stopper Decreases Postoperative Bleeding and Number of Transfusions in Patients Treated with Clopidogrel: A Double-blind, Placebo-controlled, Randomized Clinical Trial

BACKGROUND The risk of reoperation due to bleeding after open heart surgery is 2.2%-4.2%. Patients who undergo reoperation have a two to six times greater mortality rate. Risk factors for reoperation include: older age, low body mass index, time on extracorporeal circulation, and emergency operations. In coronary artery bypass graft (CABG) patients who are treated preoperatively with antiplatelets, including clopidogrel, the source of postoperative bleeding may be difficult to detect. The aim of this study was to investigate the effectiveness of local Ankaferd blood stopper (ABS) to prevent mediastinal bleeding in CABG patients who were treated with clopidogrel and acetylsalicylic acid (ASA) preoperatively. METHODS Twenty-five emergency CABG patients premedicated with clopidogrel and ASA as antiplatelet drugs were included in the study (Group 1). An additional twenty-five patients who were premedicated with the same antiplatelet agents were selected as a control group (Group 2). Preoperative clinical characteristics of the two groups were comparable. At the end of the surgery, 4-10 mL of ABS solution was sprayed on the mediastinal and epicardial tissue following protamine administration in Group1. We compared postoperative total mediastinal bleeding, reoperation rate and total blood and blood products transfused between the two groups. RESULTS There was no mortality in either of the two groups. Mean postoperative bleeding was 430 mL in the ABS group, and 690 mL in the CG group (P = .044). In the ICU, bleeding in groups 1 and 2 was 610 mL and 980 mL, respectively (P = .025); total bleeding from the mediastinum was 830 mL and 1490 mL, respectively (P = .001) and the amount of autotransfusion was 210 mL and 400 mL (P = .003). Total transfusion of PRBCs in the operating room in groups 1 and 2 was 0.3 and 0.8, respectively (P = .003). No patients in the ABS group needed surgical revision due to severe bleeding or cardiac tamponade. CONCLUSION The use of local ABS reduces bleeding, transfusion requirements of packed red blood cells, platelets and total blood units in patients premedicated with clopidogrel and ASA undergoing emergent CABG .

Does oral hygiene trigger carotid artery intima-media thickness?

BACKGROUND AND PURPOSE The aim of this study was to evaluate whether poor oral hygiene is associated with the intima-media thickness of the carotid arteries, which is one of the predictors of future progression of subclinical atherosclerosis. METHODS We selected 108 patients during periodontal examinations according to their oral hygiene. The patients had no history of atherosclerotic disease. The results of carotid artery B-mode ultrasonography examinations were analyzed at baseline and after a mean of 7.8 months. Patients were scored on the DMFT index for the number of decayed (D), missing (M), and filled (F) teeth (T). We also used the Silness-Loe plaque index (SLI) to evaluate oral hygiene and dental plaque. The patients were divided into 2 groups according to DMFT and SLI criteria. Group I had a DMFT index of 0 to 3 and an SLI score of 0 or 1; group II had a DMFT index of 4 to 28 and an SLI score of 2 or 3. RESULTS Dental status and oral hygiene were significantly associated with carotid artery intima-media thickness. Patients with increasing DMFT and SLI indices were correlated with intima-media thickness of the carotid artery. CONCLUSIONS Chronic poor oral hygiene and tooth loss are related to subclinical atherosclerotic changes in the carotid arteries and might be indicative of future progression of atherosclerosis.

Comamonas testosteroni endocarditis in Turkey: A case report and review of the literature

Introduction: Comamonas testosteroni is a gram-negative bacillus which commonly occurs in various environments worldwide. Comamonas testosteroni is rarely recognized as a human pathogen. The case we report is the first Comamonas testosteroni endocarditis in Turkey and the fourth case in the world. Case Presentation: A 51-year-old male patient with a history of chest pain, dyspnea, and tachycardia was admitted to our hospital. Coronary angiography and echocardiography results revealed mobile lesions and plaques in aortic valve. Cardiovascular surgery was performed; aortic valve vegetation was detected and the aortic valve was excised. Aerobic culture was studied. After the biochemical identification tests and the use of VITEK-2 Compact (Biomerieux, France) automated microbial identification system, pathogenic bacteria was identified as Comamonas testosteroni. The patient who had no risk factors was diagnosed with endocarditis and treated with Ciprofloxacin. The case recovered from Comamonas testosteroni infection. Conclusion: There has been an increase in bacterial infections caused by Comamonas testosteroni and antibiotic resistance of the bacteria. For this reason, Comamonas testosteroni infections have increasingly become important. There have only been four cases from Turkey so far. This paper also examines the other cases in the literature as a whole.

Evaluation of Myocardial Contractility Determination with Tissue Tracking Echocardiography after Levosimendan Infusion in Patients with Poor Left Ventricular Function and Hemodynamics

BACKGROUND The aim of this study was to assess the effect of conventional inotropic drugs compared to levosimendan using tissue tracking echocardiography in the early postoperative period for patients with low ejection fraction undergoing coronary artery bypass graft (CABG) surgery. METHODS We prospectively analyzed 115 patients (69 male, 46 female) who planned for elective coronary artery bypass surgery with low ejection fraction, ≤% 30, from September 2012 to December 2013. Patients were divided into two groups. Levosimendan was used at a loading dose of 15 μg/kg/min for the first twenty minutes, and continued at a maintenance dose of 0.2 μg/kg/min six hours before the anesthetic induction in group I (n = 47, 23 male, mean age 67.16 ± 4.72 years). Dopamine at 10 μg/kg/min and/or dobutamine at 10 μg/kg/min were used at the time of weaning from cardiopulmonary bypass in group II (n = 68, 47 male, mean age 65.43 ± 6.12 years). The patients were evaluated preoperatively and on the fifth postoperative day by transthoracic echocardiography. Patients were also evaluated just before the cardiopulmonary bypass and at the 12th and 24th hours on the first postoperative day by transesophageal echocardiography. Student t test and χ2 test were used for statistical analyses. RESULTS There were no significant differences in demographics and preoperative hemodynamic parameters between groups I and II. Hemodynamic and echocardiographic parameters were significantly better in group I receiving levosimendan, compared to group II. CONCLUSION Levosimendan enhances functional myocardial tissue mass and ensures positive hemodynamic effect in the early postoperative period in patients with low ejection fraction undergoing elective CABG.

Brain diffusion changes in unilateral carotid artery stenosis with non-shunt endarterectomy: Correlation with white matter lesions

OBJECTIVE Carotid stenosis is associated with hemodynamic cerebral ischemia. Diffusion-weighted MR imaging allows for the assessment of changes related to alterations in tissue integrity. The aim of this study was to investigate (a) whether white matter lesions (WML) and apparent diffusion coefficient (ADC) values differ between ipsilateral and contralateral hemispheres, (b) whether ADC values are related to WMLs and common vascular risk factors, and (c) whether ADC values differ after carotid endarterectomy (CEA) without a shunt in patients with unilateral internal carotid artery stenosis (ICAS). METHODS Twenty-five patients (16 men, 9 women; mean age of 68 years) with unilateral ICAS (≥ 70% carotid stenosis) were assessed with brain MRI before and after CEA, prospectively. Two experienced radiologists scored the WMLs. Bilateral ADC values in anterior and posterior periventricular WM, occipital WM, and thalamus were evaluated on preoperative and postoperative MRI. Differences in ADC values and WML scores between the two hemispheres were assessed and associations between ADC values, WML scores, and explanatory variables (e.g., age, sex, vascular risk factors) were analyzed. RESULTS WMLs were significantly greater and ADC values were elevated in the ipsilateral cerebral WM. After CEA, ADC values rapidly decreased but remained higher than within the contralateral hemisphere. Ipsilateral hemispheric ADC values were associated with basal ganglia WMLs. No association between ADC values and vascular risk factors was found. CONCLUSION ICAS is associated with increased diffusion in normal-appearing WM in comparison to more prominent chronic ischemic lesions. CEA has a partial effect on diffusion. These cerebral changes may be related to chronic low-grade ischemic damage that is induced by ICAS.

Effects of single aortic clamping versus partial aortic clamping techniques on post-operative stroke during coronary artery bypass surgery.

Background The aim of this study was to compare the effects of single-clamping and partial-clamping techniques on postoperative stroke during coronary artery bypass surgery. Methods Between December 2008 and December 2012, 2 000 patients who underwent coronary artery bypass grafting in two hospitals were analysed. Post-operative neurological complications were analysed retrospectively in these patients. The cases were divided into two groups: in group 1, 1 500 patients were analysed, in whom proximal anastomosis was performed with partial clamping in a beating heart (n = 1 500, 846 male, 654 female; mean age 63.25 ± 5.72 years; range 43–78 years). In group 2, 500 patients were analysed, in whom proximal anastomosis had been performed by other surgical teams in another hospital, with cross clamping in a resting heart with cardioplegia (n = 500, 296 male, 214 female; mean age 64.83 ± 8.12 years; range 41–81 years). During 30 days post-operatively, neurological deficits, stroke incidence and the relationship of the clinical situation to mortality were analysed. Results For both groups, patients were similar in terms of patient characteristics. In group 2, cross-clamp duration and perfusion time were longer; however, time of hospital stay was similar in the two groups. Post-operative stroke was seen in 26 patients in group 1 (1.73%) and in nine in group 2 (1.8%). The difference between the two groups was not statistically significant (p = 0.92). All stroke patients were over the age of 55 years. Seven of the stroke patients died (21.1%). In total, 31 patients died because of multiple organ failure in the postoperative 30 days (group 1: 1.6%; group 2: 1.4%) (p = 0.91). Smoking, diabetes mellitus, hypertension, atrial fibrillation, peripheral vascular disease and hypercholesterolaemia were found to be factors that affected stroke development. Mean duration of hospital stay was 5.1 ± 2.8 days in group 1 and 4.9 ± 3.6 days in group 2 and the difference between the two groups was not statistically significant (p = 0.46). Conclusion In patients without plaques in the aorta, performing partial clamping did not increase stroke incidence.

Thrombosed left circumflex artery aneurysm presenting with myocardial infarction

Coronary artery aneurysms are life-threatening conditions that are quite uncommon in adults. They are observed in 1.1% to 4.9% of patients undergoing coronary angiography. They are usually located in the right coronary artery, may sometimes be thrombosed or rupture, and occasionally reach an enormous size leading to compressive symptoms. We report a case of thrombosed left circumflex artery aneurysm presenting with myocardial infarction. The thrombosed aneurysm, which could not be clearly demonstrated by coronary angiography, was definitively diagnosed by coronary computed tomography angiography. No operation was planned owing to total thrombosis of the aneurysm.

Carotid and popliteal artery intima-media thickness in patients with poor oral hygiene and the association with acute-phase reactants.

Purpose The aim of this study was to evaluate whether poor oral hygiene is associated with carotid and popliteal arterial intima–media thickness, which is one of the predictors of future progression of sub-clinical atherosclerosis, and high-sensitivity C-reactive protein (hsCRP) and fibrinogen levels. Methods A specialised dentist checked the patients and selected 550 patients during periodontal examinations, according to their oral hygiene. The patients had no history of atherosclerotic disease. Carotid and popliteal artery B-mode ultrasonographic examinations and hsCRP and fibrinogen levels were analysed at baseline and after a mean of 6.2 months. The patients were scored on the DMFT index for the number of decayed (D), missing (M), and filled (F) teeth (T). We also used the Silness-Loe plaque index (SLI) to evaluate oral hygiene and dental plaque. The patients were divided into two groups using the DMFT and SLI criteria. Group I had a DMFT index score from 0 to 3 and SLI index score of 0 or 1. Group II had a DMFT index score from 4 to 28 and SLI index score of 2 or 3. Results A significant association was observed between dental status, oral hygiene, carotid and popliteal artery intima–media thickness and hsCRP level. Patients with increasing DMFT and SLI scores correlated with increasing carotid artery intima–media thickness. Conclusions The results clearly showed that chronic poor oral hygiene and tooth loss are related to sub-clinical atherosclerotic changes in the carotid arteries and may be indicative of future progression of atherosclerosis.