Murat Basaran

The benefits of continuous ultrafiltration in pediatric cardiac surgery

Background—Systemic inflammatory response and capillary leak syndrome, caused by extracorporeal circulation, have negative effects on the function of vital organs during the postoperative period. Modified ultrafiltration (MUF) has been developed as an alternative method to reduce the detrimental effects of cardiopulmonary bypass. The aim of this prospective, randomized study is to analyze the effects of MUF in a pediatric population undergoing congenital cardiac surgery. Methods—Twenty‐seven patients who underwent open‐heart surgery at our institution were included in this prospective study. They were randomized into two groups as follows: Group I (n=14) of conventional ultrafiltration during bypass and Group II (n=13) receiving both conventional and modified ultrafiltration during and after the cessation of the bypass, respectively. The amount of prime volume, postoperative chest drain loss, transfusion requirements, hemodynamical parameters, duration of mechanical ventilatory support, and length of intensive care unit stay were compared between the two groups. During the postoperative period, the concentrations of hematological, biochemical and inflammatory parameters were also compared by analyzing the blood samples obtained at various time points. Results—MUF resulted in a significant increase in hemoglobin, hematocrit and platelet levels, and significantly reduced the amount of chest tube output and transfused blood and blood products. MUF also shortened the duration of postoperative mechanical ventilatory support, length of the intensive care unit stay and improved postoperative hemodynamical parameters. During the early postoperative hours, IL‐8 is significantly reduced in patients undergoing MUF, however, the concentrations of IL‐8 were similar in both groups at the end of 24 h. Conclusions—MUF decreases the duration of mechanical ventilatory support, the length of intensive care unit stay, the need for blood transfusion and improves postoperative hemodynamics. It is associated with increased levels of hemoglobin, hematocrit and platelets. We can conclude that MUF attenuates the inflammatory response by decreasing the levels of inflammatory mediators.

Peri-operative comparison of different transient external shunt techniques in bidirectional cavo-pulmonary shunt

OBJECTIVE In patients with functional single ventricular physiology, the avoidance of cardiopulmonary bypass offers many advantages including earlier extubation, decreased necessity of inotropic support, improved hemodynamical status and reduced likelihood of post-operative prolonged pleural effusion. We believe that the bidirectional cavopulmonary anastomosis operations may be performed with transient external shunt techniques. The purpose of this prospective study is the peri- and post-operative comparison of different transient external shunt methods used in bidirectional cavopulmonary shunt operations. METHODS Between years 1997 and 2000, 30 patients have undergone bidirectional cavo-pulmonary shunt operation by using three different types of external shunt. The mean patient age was 13 months (range, 3 months-3 years). Previous operations had been performed in ten patients (33%). All patients were divided into three groups according to type of external shunt used. In group A (ten patients), the transient external shunt was constructed between superior vena cava and right atrium by uniting two standard venous cannulas with a Y-connector. In group B (ten patients), the external shunt was performed with a single short venous cannula constructed between superior vena cava and right atrium. In group C (ten patients), the external shunt was constructed between superior vena cava and left pulmonary artery by using a single short venous cannula. During operation, central venous pressure (CVP), arterial O(2) saturation and mean arterial blood pressure were recorded continuously. RESULTS All operations are completed without the establishment of cardiopulmonary bypass. Hospital mortality was 3.3%. One patient in group A died because of low cardiac output at the end of postoperative day 2. All patients were extubated within 4h. In groups A-C mean superior vena caval pressures were measured 28, 24 and 21 mmHg, respectively during superior vena cava-right pulmonary artery anastomosis. In both groups A and B patients, arterial O(2) saturation decreased to a minimum 53+/-2 and 53+/-2%, respectively during the operation. In the group C, minimum arterial O(2) saturation was measured 82+/-2%. Although mean arterial pressure decreased in all groups during clampage; in group C patients, this drop is not significant. CONCLUSION Based on the study presented here, bidirectional cavo-pulmonary anastomosis can be carried out by using different types of transient external shunt. The best hemodynamical condition and arterial O(2) levels were achieved with the shunt constructed between superior vena cava and left pulmonary artery.

Surgery of the carotid artery : Local anaesthesia versus general anaesthesia

Abstract Objective: Carotid artery surgery is safely and commonly performed under general, regional or local anaesthesia. The aim of the study was to compare local and general anaesthesia in carotid artery surgery in order to establish whether differences exist in terms of peri-operative results, use of intra-operative shunts and costs. Methods: We retrospectively reviewed the data on 426 patients who underwent carotid endarterectomy with either local or general anaesthesia at our institution over a four-year period. All available clinical, pathologic and postoperative data were reviewed and analyzed for postoperative results. Surgical indications, outcome, operative techniques, and complications were compared. Results: A total of 306 carotid endarterectomy operations under local, and 127 under general anaesthesia were performed and analyzed. Groups were similar in terms of age, sex and pre-operative risk factor distribution. The local anaesthesia group was associated with a lower incidence of shunt placement and operative time when compared to the general anaesthesia group. Postoperative intensive care unit requirement, hospital stay and costs were also lower with local anaesthesia. Significant difference in neurological complications and mortality rate was not observed between the two groups. Conclusion: Carotid endarterectomy performed under local or general anaesthesia is associated with low morbidity and mortality rates. Local anaesthesia enables the surgeon to assess the neurological status during the procedure. It is also associated with decreased shunt usage, decreased operative time and, in high risk patients, lower intensive care unit requirement and hospital stay.

Visceral artery aneurysms.

OBJECTIVE Visceral artery aneurysms are rare vascular malformations and the literature lacks satisfactory general information about the pathology. The aim of this study was to review our experiences in the diagnosis and treatment of visceral artery aneurysms. MATERIALS AND METHODS We retrospectively reviewed data on 10 patients who were diagnosed with visceral artery aneurysms at our institution between June 2002 and September 2005. All available clinical, pathologic, and postoperative data were reviewed and analyzed for postoperative outcome. RESULTS Four splenic artery aneurysms, 2 hepatic artery aneurysms, 5 renal artery aneurysms, 1 superior mesenteric artery aneurysm, and 1 inferior mesenteric artery aneurysm (13 total visceral artery aneurysms) were diagnosed in 10 patients. All the patients were treated except 1 patient with bilateral renal artery aneurysms. One patient required emergent surgical treatment due to splenic artery aneurysm rupture. Only 1 patient underwent endovascular treatment (ie, coil embolization for a superior mesenteric artery aneurysm); otherwise all the patients were treated surgically on an elective basis. Surgical treatment modalities included ligation with exclusion in 4 patients (2 splenic artery aneurysms, 1 renal artery aneurysm, 1 hepatic artery aneurysm) and resection with revascularization in 4 patients (1 splenic artery aneurysm, 2 renal artery aneurysms, 1 hepatic artery aneurysm, 1 inferior mesenteric artery aneurysm). Histopathologic examination of the vascular materials revealed major atherosclerotic changes except one that showed inflammatory vasculitic changes. One patient required bleeding revision, and mortality did not occur in any of the patients. CONCLUSIONS Visceral artery aneurysms are rare and potentially life-threatening vascular disorders. The number of cases diagnosed every year increases because of advanced radiologic diagnostic methods and screening programs. Careful consideration and early management of these malformations can be life saving.

Aneurysm of the kinked extracranial internal carotid artery case report and review of the literature.

Aneurysms at the extracranial portion of the internal carotid artery are rare disorders. In the largest series, McCollum reported only 37 cases over a 21 year period (1) and Moreau reported 35 cases over a 24 year period (2). This uncommon but interesting vascular disorder usually presents as a parapharyngeal pulsatile mass. It can be partially or completely thrombosed and can thereby cause embolization or compression of neuronal vasculature. Ruptures and ischaemic events are other complications. Therefore the mortality rate in nonoperated patients is very high. The major etiologic factor is atherosclerosis. Sometimes, trauma may be another cause. Surgery is recommended for symptomatic aneurysms in patients at all ages. The aim of this paper is to report the symptoms and clinical findings of a patient with a kinked extracranial internal carotid artery with aneurysm and to review the literature.

Anomalous Origin of the Left Coronary Artery From the Pulmonary Artery Associated With Severe Left Ventricular Dysfunction: Results in Normothermia

BACKGROUND Repair of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) carries a high risk of operation, particularly in those with poor left ventricular function. In this study, we assessed the outcomes of patients who presented with severe preoperative left ventricular dysfunction (shortening fraction <15%) who underwent the repair under normothermic bypass. METHODS Since September 2002, 21 infants with severe left ventricular dysfunction underwent surgical repair using a direct coronary reimplantation technique. Mean age of patients was 5.3 +/- 3.8 months. Moderate or severe mitral regurgitation present in 5 patients was not addressed at the operation. Repair was performed under normothermic cardiopulmonary bypass and myocardial protection was achieved by intermittent antegrade normothermic blood cardioplegia. RESULTS Mean cardiopulmonary bypass and cross-clamp times were 153.5 +/- 51 and 50 +/- 14.5 minutes, respectively. There was one (4.7%) early death because of sudden cardiac arrest 48 hours after successful weaning from mechanical ventilation. One patient required urgent left coronary artery stenting on the 34th postoperative day because of early reimplantation failure. There was no late death. Echocardiographic evaluation revealed a significant improvement in terms of shortening fraction (preoperative, 10.3 +/- 3.2% vs follow-up, 33 +/- 7.7%, p < 0.0001). CONCLUSIONS Our results suggest that the repair of anomalous origin of the left coronary artery from the pulmonary artery can be accomplished with acceptable mortality and morbidity rates even in patients having severely depressed left ventricular function. Normothermic cardiopulmonary bypass is safe and effective in children who have a limited tolerance to further ischemic insult.

Epidural Anaesthesia and Mini-Laparotomy for the Treatment of Abdominal Aortic Aneurysms in Patients with Severe Chronic Obstructive Pulmonary Disease

Abstract Purpose: The purpose of this study is to compare the use of epidural and general anaesthesia techniques in the treatment of abdominal aortic aneurysms (AAA) through mini-laparotomy in patients with severe chronic obstructive pulmonary disease (COPD). Methods: Between March 2002 and October 2005, 23 patients with severe COPD underwent elective infrarenal abdominal aortic aneurysm repair. Endovascular therapy could not be established due to financial reasons and health insurance policies. All the operations were performed through mini-laparotomy, using epidural anaesthesia on 10 patients (Group I) and general anaesthesia on the remaining patients (Group II). Pulmonary disease was diagnosed by clinical history and pulmonary function tests. The diagnosis of severe COPD was made with the presence of one or more of the following criteria: Room air PaO2 < 60 mmHg, PaCO2 > 45 mmHg in arterial blood gas samples, FEV1 < 50% of predicted value and FVC < 75% of predicted value in respiratory function tests. Results: There was no significant difference between the ages, sex, pre-operative morbidity status, operation time and total blood loss of the patients in the two groups. Postoperative intensive care unit requirement, postoperative pulmonary complications and hospital stay were significantly higher in group II. All patients tolerated surgery safely. There was one in-hospital mortality from group II on the 35th postoperative day due to prolonged entubation and sepsis related to pulmonary infections. There was no late morbidity or mortality related to the technique in the postoperative follow-up period of the discharged patients. Conclusion: Epidural anaesthesia for abdominal aortic aneurysm repair through mini-laparotomy is feasible and should be especially considered in patients with severe COPD where endovascular treatment could not be performed.

Aortic stiffness in diabetes mellitus--association with glutamine and heat shock protein 70 expression: a pilot study based on an experimental rodent model.

Background: Diabetes mellitus (DM) alters arterial wall compliance and causes aortic stiffness, which is a predictor of vascular mortality. Heat shock proteins (HSPs) are involved in the protection of cells under stress. We evaluated aortic stiffness in DM and the effects of glutamine (which induces HSP 70) on HSP 70 levels in experimental DM. Materials and methods: Male Sprague-Dawley rats (n = 30) were divided into three groups: Control (Group 1), DM (Group 2) and glutamine-treated DM (Group 3). DM was induced using streptozocin injection. Group 3 rats received two doses of glutamine during the fourth week. Blood and infrarenal aortic tissue samples were obtained for analysis at the end of the fourth week. Results: Compared with Group 1, serum HSP 70 levels were significantly increased in Groups 2 and 3. Aortic HSP 70 was increased in DM. There was a significant difference in aortic HSP 70 with glutamine injection (Group 1 versus Group 3). DM also interfered with the elastin content of the aorta. There was a significant correlation between the serum glucose and serum and aortic HSP 70 levels and between serum and aortic HSP 70 levels; as well as between severity of DM and aortic elastin levels. Conclusions: DM causes aortic stiffness and this may contribute to the increase in mortality and morbidity associated with DM. The expression of HSP 70 may become a therapeutic target.

Comparison of transperitoneal and retroperitoneal approaches in abdominal aortic surgery.

Abstract Background: The transperitoneal approach (TP) to the aorta is the most widely accepted surgical approach in aortic surgery as it is simple, fast and provides excellent exposure of the intra-abdominal cavity and vascular structures. In recent years, there has been an increasing interest in the retroperitoneal (RP) approach to the aorta since it has been described as having a better outcome, i.e., preserving pulmonary function and gastro-intestinal physiology, reducing the intra-operative blood loss, minimising patient discomfort or pain, decreasing the incidence of wound complications and shortening ICU and hospital stay. The aim of this study is to compare the transperitoneal and retroperitoneal approaches in aortic surgery for aorto-iliac occlusive disease (AIOD). Methods: From December 2003 to June 2006, a total of 153 consecutive patients who had undergone aortic surgery for AIOD, were studied retrospectively. The TP approach was used in 85 patients and the RP approach in 68 patients. Demographic features, intra-operative and postoperative data were analysed and compared according to the approach used. Results: The mean operating time (83.6 ± 23 vs. 104.4 ± 30 min, p < 0.001) and mean aortic cross-clamp time (18.4 ± 3 vs. 15.2 ± 3 min, p < 0.0412) were significantly longer in the RP group. Peri-operative blood loss (700 ± 350 vs. 650 ± 330 ml, p < 0.683) and mortality rate < 30 day (1/1.2% vs. 0/0.0%, p < 0.896) were similar between the groups. The operative 30 day mortality rate was 0.7% (1 of 153) overall. The RP group had an earlier return of bowel functions (17.1 ± 3 vs. 24.2 ± 5 hrs, p < 0.001), earlier resumption of diet (26.4 ± 4 vs. 31.4 ± 5 hrs, p < 0.001), shorter period of intubation (3.5 ± 2 vs. 6.5 ± 3 hrs, p < 0.001), ICU stay (1.5 ± 1 vs. 4.2 ± 1 hrs, p < 0.001) and hospital stay (4.0 ± 1 vs. 5.9 ± 1 days, p < 0.001). Mean effort-pain scores were significantly lower in the RP group (3.8 ± 1 vs. 5.3 ± 1, p < 0.001). Incidence of pulmonary complications (4.4%, 3 of 68 vs. 7.3%, 8 of 85, p < 0.001), paralytic ileus (1.5%, 1 of 68 vs. 3.5%. 3 of 85, p < 0.001) were also lower in the RP group. Wound complications were more common in the TP group (4.7%, 4 of 85 vs. 10.3%, 7 of 86, p < 0.001). Most cases in both groups were related to incisional hernia or evisceration. Conclusion: This report presents our experience with the use of TP and RP approaches in a patient population merely consisting of AIOD. The RP approach was associated with a significantly lower incidence of postoperative pulmonary complications, rapid recovery of gastro-intestinal functions, shorter ICU and hospital stay, less peri-operative blood loss and lower mean effort-pain scores. We conclude that the RP approach is a safe and feasible technique that exposes patients to less postoperative complications.

Rhabdomyolysis Following Accidental Intra-arterial Injection of Local Anesthetic

Drug-induced myopathy, also named Nicolau syndrome, is a well-known phenomenon following intramuscular injection of certain agents, most commonly reported with penicillin or diclofenac. The mechanism responsible for the pathology is proposed to be incidental administration of the drug into the small arterioles. In this report, we present a Nicolau syndrome-like case that developed following accidental injection of a local anesthetic agent into the femoral artery during coronary angiography.