Murat Güvener

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.

Hemodynamic effects of left upper extremity arteriovenous fistula on ipsilateral internal mammary coronary artery bypass graft.

OBJECTIVE Arteriovenous fistula (AVF) in patients undergoing hemodialysis (HD) may cause coronary left internal mammary artery (IMA) steal. This phenomenon was demonstrated by few prospective studies with limited number of patients and case reports. We aimed to demonstrate with a relatively larger patient population that the AVF may cause ipsilateral IMA steal. METHODS We included 22 prospective patients undergoing HD who had left IMA to left anterior descending artery graft and left upper limb AVF. Right IMA was taken as control. Flows were assessed by using color Doppler ultrasonography. RESULTS The mean age was 57.8 ± 9 years. Statistically nonsignificant increases in AVF flow and decreases in left IMA flow were observed during HD compared with pre-HD. Moreover, fistula localization did not affect median left IMA flows (for peak systolic velocity [PSV] 43.7 versus 70 cm/s, respectively; p = 0.7, and for end diastolic velocity [EDV] 3.4 versus 6.5 cm/s, respectively; p = 0.7). We have not detected significant difference in left IMA flows during HD (median values of PSV 58.4 versus 68.4 cm/s, respectively; p = 0.1, and EDV 6.4 versus 4.4 cm/s, respectively; p = 0.08). Only three patients experienced dialysis-induced reduction of ipsilateral IMA flow that was accompanied by evidence of hypokinesia of the anterior left ventricular wall without clinical angina. CONCLUSIONS Hemodynamically affected left IMA flow by ipsilateral upper extremity AVF may cause steal phenomenon. Hemodynamic differences between left and right IMAs in patients undergoing HD via left wrist and brachial fistulae are limited.

Risk factors for systemic inflammatory response after congenital cardiac surgery.

This study aims to assess the frequency of systemic inflammatory response syndrome (SIRS) following congenital heart surgery and risk factors associated with this clinical syndrome.

Pseudoaneurysm of the brachial artey in two infants following accidental artertial puncture

A pseudoaneurysm is defined as an aneurysmatic sac surrounded by fibrous tissue instead of other vascular layers such as the muscular one. It is a rare incident in infants especially in the brachial artery. Blunt trauma and vascular access attempts are the most common etiologic factors. We present two infants with brachial artery pseudoaneurysm in the antecubital region following accidental arterial puncture.

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.

Results From Extrapleural Clipping of a Patent Ductus Arteriosus in Seriously Ill Preterm Infants

Minithoracotomy for extrapleural closure of the patent ductus arteriosus (PDA) in seriously ill patients offers a fast and less invasive alternative to conventional transpleural ductal closure. This study reports the immediate postoperative clinical outcomes for 24 extrapleurally clipped premature infants presenting with congestive heart failure in high-risk comorbidity status between March 2007 and November 2010. The demographics, preoperative clinical characteristics, and postoperative outcomes of the patients, including echocardiographic assessments, were evaluated. No surgery-related mortalities occurred. Four mortalities occurred after surgery due to sepsis and bleeding diathesis. All 20 surviving patients exhibited normal left ventricular dimensions and systolic function in the immediate follow-up period. The study shows that extrapleural clip closure in seriously ill premature infants has an acceptable overall short-term mortality and complication rate with a high rate of ductal closure.

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.

Diagnosis of a Coronary Artery Anomaly by 16-Channel Computed Tomography Coronary Angiography in an Infant

[3], and echocardiography [1] have been used for the detection of coronary artery anatomic variations in tetralogy of Fallot (TOF). To our knowledge, this is the first report of multidetector computed tomography (MDCT) angiography of the coronary arteries in a small infant with TOF [4]. MDCT was performed in a 3-year-old with TOF because of suspected coronary artery anomaly on cardiac catheterization. This study was performed by 16channel Somatom sensation MDCT (Siemens Medical Systems, Germany). Technical parameters were as follows: slice thickness, 1 mm; detector collimation, 0.75 mm; reconstruction index, 1 mm; table speed, 2.8– 3.4 mm/rotation; and gantry rotation time, 0.42 seconds, with a temporal resolution of 210 msec. Axial images were transferred to a separate workstation (Leonardo Siemens) with advanced volume-rendering software. After intravenous contrast injection (1 cc/kg) the entire heart was scanned during single breath hold (approximately 10–20 seconds). The MDCT data were reviewed on a workstation with interactive scrolling, multiplanar reconstruction, and maximum intensity projections. The coronary artery system and pulmonary artery branches were successfully visualized (Figs. 1 and 2). A large branch coronary artery arising from the left anterior descending artery was shown crossing the right ventricular outflow tract that was not visualized by cardiac catheterization. These findings were confirmed at surgery. Selective coronary angiography has been accepted as a gold standard for coronary imaging in TOF. Other imaging modalities include transthoracic and transesophageal echocardiography and magnetic resonance imaging. Even in surgery, an anomalous vessel crossing the right ventricular outflow track could be missed, especially when the coronary arteries are obscured by the overlying myocardium, epicardial fat, or scar tissue in patients who have undergone prior palliation. This report demonstrates that 16-channel MDCT coronary angiography can define the coronary artery course noninvasively with high-quality images in small infants using minimal amounts of contrast material and short examination times.

Giant aneurysm of the ductus arteriosus in an infant with Pierre-Robin sequence

An aneurysm of the ductus arteriosus is a very rare but potentially fatal abnormality [2]. We describe a primary infantile type, giant aneurysm of a non-patent ductus arteriosus, in a patient with Pierre–Robin sequence (hypoplastic mandible, micrognathia, glossoptosis, and cleft palate) [3]. A 4-month-old male was admitted to the hospital for increasing dyspnea and dysphagia and physical examination findings consistent with Pierre–Robin sequence. A mediastinal mass occupying two-thirds of the left hemithorax was discovered on routine chest roentgenogram (Fig. 1). Axial computerized tomography scan of the chest with contrast revealed a giant vascular mass originating from the region of the aortic isthmus and expanding to the left hemithorax. It appeared to be connected to the proximal descending aorta, adjacent to the left pulmonary artery; the trachea was deviated to the right side of the chest (Fig. 2). Digital subtraction aortography in the left anterior oblique projection showed a direct connection of the giant aneurysm with the descending aorta (Fig. 3). Resection of the giant saccular aneurysm (10 · 7 · 7 cm) of a non-patent ductus arteriosus that invaded the upper and middle zone of left hemithorax was performed successfully with cardiopulmonary bypass. The patient’s postoperative course was uncomplicated.