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Preoperative Fibrinogen Levels as a Predictor of Postoperative Bleeding after Open Heart Surgery

BACKGROUND Open heart surgery still involving major bleeding continues to be a major challenge after cardiac surgery and is also a significant cause of morbidity and mortality. Most hemostatic factors are intercorrelated with postoperative bleeding, and fibrinogen seems the most fundamental hemostatic risk factor for open heart surgery. METHODS The study included 97 patients who underwent elective coronary artery surgery (78 men and 19 women; mean age, 60.9 +/- 10.3). Preoperative blood samples were obtained and preoprative quantitative determination of plasma fibrinogen levels were measured by the clotting method of Clauss using the fibrinogen kit. Patients were operated on by the same team and the same technique. The total amount of drainage blood from chest tubes was recorded after termination of operation. RESULTS There were statistical significance between the fibrinogen levels and the drainage (r = -0.897, P < .001). Chest drainage was a mean of 972 mL (range, 240-2445 mL) in the first 48 hours after sternotomy closure. Fibrinogen level and relation to age was statistically significant (P = .015). There was no statistical significance between fibrinogen levels and gender (male gender = 400.7 +/- 123.0 versus female gender = 395.6 +/- 148.1; P = .877) and between drainage and gender (male gender = 968.2 +/- 538.5 versus female gender = 990.0 +/- 554.7; P = .876). Two patients (2%) died early after the surgery. There were no significant differences between the postoperative bleeding and cardiopulmonary bypass time (P = .648) or cross-clamp time (P = .974). CONCLUSION The results of this study suggested that low preoperative fibrinogen level appears to be a useful diagnostic marker to assess the activity of the coagulation system, and that its preoperative level may serve as a potential risk factor for postoperative bleeding after coronary artery bypass surgery.

Predictive significance of plasma levels of interleukin-6 and high-sensitivity C-reactive protein in atrial fibrillation after coronary artery bypass surgery.

BACKGROUND Postoperative atrial fibrillation (AF) plays a major role in the determination of hemodynamic deterioration and can be associated with cardiovascular events after coronary artery surgery. Elevated interleukin (IL)-6 and C-reactive protein (CRP) levels in patients with AF suggest a role of inflammation in the pathogenesis of AF. We conducted a study to investigate the correlation between postoperative AF and IL-6 and high-sensitivity CRP (hsCRP). MATERIALS AND METHODS Forty-nine patients with a mean age of 60.3 +/- 10.7 years were enrolled in this study. Preoperative and postoperative first day blood samples were collected to assess the IL-6 and hsCRP levels. IL-6 levels were measured by enzyme-linked immunosorbent assay, and hsCRP was measured by rate turbidimetry method. RESULTS Fourteen patients (28.5%) developed AF postoperatively. Patients who developed AF showed elevated serum concentrations of postoperative first day IL-6 (P < .001), preoperative hsCRP (P < .005), and postoperative first day hsCRP (P < 0.001). Preoperative hsCRP levels (P < .002) and postoperative first day IL-6 (P < .001) and hsCRP (P < 0.001) levels were associated with prolonged endotracheal intubation time. Prolonged intensive care unit stay showed significant correlations with elevated levels of preoperative hsCRP (P < 0.002) and postoperative first day IL-6 (P < 0.001) and hsCRP (P < 0.001). There was also statistical significance between the AF+ and AF- groups regarding intensive care unit stay and endotracheal intubation times (P < .001 and P < .001, respectively). Cut-off points for postoperative first day IL-6, preoperative hsCRP, and postoperative first day hsCRP were 46.4 pg/mL (sensitivity = 92.9% and specificity = 80%), 0.46 mg/L (sensitivity = 71% and specificity = 75%), and 17.9 mg/L (sensitivity = 92.9% and specificity = 78%), respectively. CONCLUSIONS Elevated IL-6 and hsCRP levels in patients with postoperative AF suggest inflammatory components have a role of in the pathogenesis of AF.

Noncompaction of Ventricular Myocardium in a Patient with Congenitally Corrected Transposition of the Great Arteries Treated Surgically: Case Report

Noncompaction of the ventricular myocardium is a rare disorder that represents numerous prominent trabeculations and intratrabecular recesses in the ventricles. It is believed to represent not only an arrest in endomyocardial morphogenesis but also an unclassified cardiomyopathy. The pathology has been almost invariably associated with other congenital cardiac malformations. A female patient with noncompaction of the myocardium of both ventricles and congenitally corrected transposition of the great arteries (cTGA), situs inversus totalis, and atrial and ventricular septal defects is described. When she was 7 days old a permanent pacemaker was implanted because of complete heart block. Prazosin (Minipress), an alpha-receptor blocker, was administered, and the cardiac ejection fraction showed a striking increase from 20% to 42%. Despite careful and regular follow-up evaluations, the general condition of the patient slowly worsened. Five months after surgery she died of hepatorenal failure and low cardiac output. This case report is thought to be the first description of congenital complete heart block, cTGA, and situs inversus totalis with noncompaction of the myocardium of both ventricles.

Heat shock protein70: a new marker for subsequent atrial fibrillation development?

Atrial fibrillation (AF) is a common arrhythmia, after cardiac surgery, and it is associated with a twofold increase in cardiovascular mortality and morbidity. Reperfusion injury and inflammation associated with cardiac surgery are thought to be involved in its pathogenesis. Heat shock proteins (HSPs) are a family of chaperone proteins which assist in preservation of cellular integrity by maintaining proteins in their correctly folded state. The aim of this study was to investigate pre-postoperative heat shock protein70 (HSP70) and high-sensitivity C-reactive protein in serum from patients in preoperative sinus rhythm. We prospectively screened 45 consecutive patients admitted to the hospital for elective coronary artery bypass surgery (CABG). Electrocardiogram characteristics and cardiovascular risk profile were documented. Pre- and postoperative blood samples were collected. HSP70 value was 8.9 +/- 4.8 ng/mL in Group A (study group) preoperatively and decreased to 7.7 +/- 7.0 ng/mL postoperatively. In contrast, preoperative value of HSP70 was 4.2 +/- 2.2 ng/mL and decreased to 2.7 +/- 2.6 ng/mL postoperatively in Group B (control group). Statistical analysis showed significant difference regarding preoperative HSP70 levels in Group A compared to Group B. To our knowledge, with this study, the association of pre- and postoperative circulating HSP70 with postoperative AF was demonstrated for the first time.

Renal effects of coronary artery bypass graft surgery in diabetic and non-diabetic patients: a study with urinary neutrophil gelatinase-associated lipocalin and serum cystatin C.

Background/Aims: Cardiac surgery and diabetes are major causes of acute kidney injury (AKI). We aimed to investigate the value of urinary neutrophil gelatinase-associated lipocalin (NGAL) and serum cystatin C, as early biomarkers for prediction of AKI in diabetic and non-diabetic adult patients undergoing cardiac surgery. Methods: 15 non-diabetic and 15 diabetic adult patients undergoing cardiac surgery were enrolled. Peri-operative clinical and laboratory variables were recorded. Urinary NGAL, serum cystatin C, serum creatinine (Cre) and blood urea nitrogen (BUN) were evaluated. Results: AKI was detected in 4 patients in non-diabetic group and 12 patients in diabetic group. Urinary NGAL levels of diabetic and non-diabetic patients and serum cystatin C levels of diabetic patients exceed upper normal limits or cutoff values much earlier than BUN and Cre. cystatin C levels of non-diabetic patients remain unchanged. Cystatin C and NGAL levels of patients meeting AKI criteria and NGAL levels of patients not meeting AKI criteria exceeded upper normal limits or cut off values much earlier in than BUN and Cre. Conclusions: Measurement of cystatin C level in both diabetic and non-diabetic patients may reveal AKI earlier than NGAL and BUN. In diabetic patients, measurement of urinary NGAL and serum cystatin C levels may indicate AKI signs earlier than BUN and Cre.

Peroperative effects of fresh frozen plasma and antithrombin Iii on heparin sensitivity and coagulation during nitroglycerine infusion in coronary artery bypass surgery

Nitroglycerin (NTG) reduces the anticoagulant effects of heparin and may lead to heparin resistance. Fresh frozen plasma (FFP) and antithrombin III (ATIII) may be used for the treatment of heparin resistance. We aimed to compare the effects of FFP and ATIII on heparin requirement, coagulation parameters, and bleeding in patients undergoing coronary artery bypass graft surgery (CABGS) with moderate dose of intraoperative NTG infusion. Forty-eight patients undergoing CABGS with NTG infusion were randomly allocated to three groups. Group C served as control, whereas the patients in group P received FFP and those in group A received ATIII after anesthesia induction. ATIII activity and coagulation parameters were measured at five different times intraoperatively. Total heparin requirement, heparin consumption, and heparin sensitivity were calculated. ATIII activity and ACT were significantly higher and activated partial thromboplastin time and fibrinogen level were significantly lower during cardiopulmonary bypass in group A than in groups P and C. Heparin sensitivity was significantly higher and total heparin requirement and consumption were significantly lower in ATIII group than in other groups. ATIII administration increases heparin sensitivity and decreases heparin requirements compared with FFP in patients undergoing CABGS with peroperative NTG infusion. ATIII may be preferred to FFP in patients with heparin resistance due to NTG infusion undergoing CABGS.

Giant right atrial myxoma mimicking hepatic cirrhosis: a case report.

Cardiac myxomas are rare benign tumors of the heart. The growth rate of these tumors remains unknown. Right atrial myxoma can simulate nonspecific constitutional symptoms, such as remittent or lasting fever, weight loss, and chronic anemia, and may escape timely diagnosis until the development of severe complications such as pulmonary hypertension due to embolism from fragments originating from the tumor mass or blockage of the right atrioventricular ostium or Budd-Chiari syndrome with acute abdominal pain. We present a case of a giant right atrial myxoma mimicking hepatic cirrhosis in a 52-year-old man.

Spontaneous coronary artery dissections: three case reports and review of literature.

Primary spontaneous coronary artery dissection is one of the rare causes of acute myocardial infarction and is mostly fatal. Previous studies report that it is mostly seen in middle-aged women in the last trimester of pregnancy and early postpartum period. Clinical presentation of the disease is variable in pattern, and its severity is related to extent and development rate of dissection. Herein we present three cases of primary spontaneous left main coronary artery dissection. Two of the patients are men and the third patient is a non-pregnant 69-year-old woman. The cases were presented and discussed with review of the pertinent literature.

Plasma leptin levels increase to a greater extent following on-pump coronary artery surgery in type 2 diabetic patients than in nondiabetic patients

AIMS We aimed to evaluate whether leptin and ghrelin responses to cardiopulmonary bypass (CPB) are dependent on type 2 diabetes and whether these responses are associated with interleukin-6 (IL-6), high-sensitivity C-reactive protein (hsCRP), cortisol and insulin. METHODS We examined stress-response patterns in plasma leptin, ghrelin, hsCRP, IL-6, cortisol and insulin levels before and up to 5 days after cardiopulmonary bypass in 20 patients with type 2 diabetes and 20 patients without diabetes. RESULTS Plasma leptin levels increased significantly in both groups (p<0.05) and rose significantly higher in diabetics when compared with nondiabetic patients (p=0.004). Plasma ghrelin levels increased significantly only in diabetics (p=0.033). Patients with and without diabetes showed significantly elevated serum concentrations of IL-6, hsCRP, cortisol and insulin (p<0.005 for IL-6, hsCRP; p<0.05 for cortisol, insulin) but the difference between the two groups was nonsignificant. Leptin was independently predicted by hsCRP (p<0.05, F=2.9), gender (women p<0.001, F=4.7), body mass index (BMI p<0.0001, F=6.1) whereas ghrelin levels were not associated with any variables in the total patient population. (critical F=2.26, p≤0.05). CONCLUSIONS Acute phase response in diabetics differs by higher leptin levels independent of BMI, gender and IL-6, hsCRP, insulin and cortisol levels.

Three Unusual Cases where Cardiopulmonary Bypass Was Used in Thoracic Surgery

Cardiopulmonary bypass (CPB) is a technique which is commonly performed without any problem in cardiac surgery. CPB can also be used in patients with a tumoral mass adherent to the great vessels, in patients with critically narrowed airway, if cross-table intubation of the distal trachea is not feasible and in patients necessitating re-do surgery with extensive adhesions because it allows extensive mobilization of the heart and great vessels without compromising their function. It also allowed the central pulmonary artery to be controlled without comprising oxygenation and complete resection of a tumor localized in the A-P window. Herein we report such patients operated with CPB without any problem.