Murat Sargin

Risk factors for posterior ventricular rupture after mitral valve replacement: results of 2560 patients

OBJECTIVE Posterior ventricular rupture is a rare and fatal complication of mitral valve surgery. This study is designed to define the risk factors for left ventricular rupture after mitral valve replacement and, especially, to find out if posterior leaflet preservation is protective for posterior ventricular rupture. METHODS Between January 1996 and March 2007, 2560 patients underwent mitral valve replacement operation in our hospital. Risk factors for posterior ventricular rupture were studied with chi(2) and logistic regression analysis. RESULTS The surgery was complicated with posterior ventricular rupture in 23 (0.8%) of 2560 patients. Nineteen patients (82.6%) were female, four patients (17.4%) were male. Mean age of the patients in this group was 60+/-10. Mortality rate of the patients with posterior ventricular rupture was 86% (20 patients). Twelve patients with posterior ventricular rupture were at the age of 60 and older. Age of 60 and above was found as a highly significant risk factor for posterior ventricular rupture (OR 4.53, 95% CI 1.98-10.38, p<0.001). Posterior leaflet was preserved in 513 patients (20%) and posterior ventricular rupture did not occur in these patients. Resection of posterior leaflet was also found as a highly significant risk factor (p=0.008) for posterior ventricular rupture. Reoperation was performed in 372 patients and posterior ventricular rupture occurred in 7 of them. Reoperation was also found as a significant risk factor (OR 2.563, 95% CI 1.03-6.34, p=0.042) for posterior ventricular rupture. CONCLUSIONS Extreme annular traction and aggressive decalcification should be avoided during mitral valve resection. Posterior leaflet of the mitral valve should be preserved, especially in the older age group to prevent posterior ventricular rupture.

Safety of unilateral antegrade cerebral perfusion at 22 degrees C systemic hypothermia.

BACKGROUND The superiority of antegrade cerebral perfusion (ACP) in aortic surgery is widely accepted, but the sufficiency of unilateral cerebral perfusion and the optimal systemic temperature during the operation are still controversial. METHODS Thirty patients who underwent operation with unilateral ACP at a systemic temperature of 22 degrees C between January 2005 and September 2007 were included in this study. The mean age (+/-SD) of the patients was 58 +/- 11 years, and 21 (70%) of the patients were male. The indication for surgery was acute type A aortic dissection in 14 patients (47%), degenerative aortic aneurysm in 9 patients (30%), dissecting aortic aneurysm in 6 patients (20%), and intramural hematoma in 1 patient (3%). Supracoronary ascending aorta replacement was performed in 13 patients (43%). Eight patients (27%) underwent ascending aorta and hemiarch replacement. The Bentall procedure was performed with hemiarch replacement in 3 patients (10%). Three patients (10%) underwent total aortic arch replacement, and 2 patients (7%) underwent the Bentall procedure. The ascending aorta, aortic arch, and descending aorta were replaced in 1 patient (3%). RESULTS Hospital mortality was limited to 1 patient (3.3%). A permanent or transient neurologic deficit was not detected in any of the survivors. The mean cardiopulmonary bypass, aortic cross-clamp, and ACP times were 144 +/- 40 minutes, 82 +/- 28 minutes, and 30 +/- 11 minutes, respectively. The mean mechanical ventilation time was 18 +/- 9 hours. The mean stay in the intensive care unit was 2.3 +/- 1.1 days, and the mean hospital stay was 12 +/- 6 days. CONCLUSION Unilateral ACP with systemic hypothermia at 22 degrees C is safe and has satisfactory clinical results. Establishing ACP via cannulation of the right axillary artery is fast and simple. The presence of fewer cannulas in the operation field provides an operative condition as convenient as the deep hypothermic circulatory arrest technique.

The Severity of Positional Mitral Regurgitation during Off-Pump Coronary Artery Bypass Grafting

BACKGROUND The aims of this study were to elucidate the incidence of mitral regurgitation during off-pump coronary artery bypass (OPCAB) surgery to evaluate the relationship of the changes with ventricular function and possible mitral valve regurgitation caused by positioning. METHODS Included in the study were 60 consecutive patients who underwent CAB grafting on the beating heart. We monitored several hemodynamic variables (systolic arterial pressure, mean arterial pressure, right atrial pressure, pulmonary capillary wedge pressure, and heart rate) at baseline and after each anastomosis and used transesophageal echocardiography (TEE) routinely after sternotomy, during each anastomosis, and after completion of the operation. Valvular functions, ejection fraction, and wall motion systolic index were recorded during each TEE evaluation. RESULTS All of the patients underwent complete revascularization. We performed 132 consecutive OPCAB anastomoses in 60 patients (60 left anterior descending artery [LAD], 20 right coronary artery [RCA], 45 left circumflex coronary artery [LCX], and 7 diagonal artery grafts). During LCX anastomosis, 38 (84.4%) of 45 patients developed moderate mitral regurgitation. The wall motion score index (WMSI) significantly increased during CX grafting, as was demonstrated by higher WMSI values than for the RCA, diagonal, and LAD grafts. The ejection fraction was decreased significantly during CX and RCA anastomoses compared with baseline levels. The hemodynamic changes were in accord with these findings. The greatest hemodynamic compromise was seen during CX anastomosis. CONCLUSION Positional mitral regurgitation occurs frequently and is a major contributor to hemodynamic instability during posterior- and lateral-wall revascularization during the OPCAB procedure.

Do N-acetylcystein, beta-glucan, and coenzyme Q10 mollify myocardial ischemia-reperfusion injury?

BACKGROUND N-acetylcysteine, beta-glucan, and coenzyme Q10 have been shown to have antioxidant and anti-inflammatory effects on reperfusion injury. The aim of our study was to determine and evaluate the effects of these agents on myocardial ischemia-reperfusion injury. METHODS Forty-four New Zealand white rabbits, all female, weighing 2.4 to 4.1 kg (mean, 3.6 kg) were used in the study. Four study groups of 11 animals were arranged by randomization. The groups were the control group (group C), a group premedicated with coenzyme Q10 (group Q), a group premedicated with beta-glucan (group betaT), and a group premedicated with N-acetylcysteine (group N). After exploration of the heart, a basal myocardial biopsy was taken from the anteroapical left ventricle, and the first blood sampling was done before ischemia. For the ischemia-reperfusion experiments, the major left anterior descending artery was occluded after baseline measurements. After a 45-minute transient ischemic period, the heart was perfused for 120 minutes. After perfusion, the second myocardial biopsy was taken from the anteroapical left ventricle, and the second blood sampling was done. Blood and tissue analysis were performed and evaluated statistically. RESULTS Baseline and reperfusion levels of glutathione peroxidase, superoxide dismutase, malonyldialdehyde, and nitric oxide changed significantly. While malonyldialdehyde levels increased in group C, they decreased in the other study groups (P =.001). The increases in glutathione peroxidase and superoxide dismutase levels were significant in all groups except group C (P =.0001 and P <.05, respectively). Levels of nitric oxide were found to be decreased in group C, whereas they increased in the other groups (P =.001). CONCLUSION Antioxidant medication may help in lowering the risk of myocardial ischemia-reperfusion injury. All the medications in our study are shown to have effective roles in preventing ischemia-reperfusion injury to some extent through their antioxidant properties.

An approach to cultural adaptation and validation: the Intermittent Claudication Questionnaire

Abstract The objective of this study was to perform a cultural adaptation and define the validity of the Turkish version of the Intermittent Claudication Questionnaire (ICQ) in order to provide a practical instrument for the evaluation of the impact of intermittent claudication (IC) on patients’ quality of life and response to therapy. A standard ‘forward–backward’ translation method was used to translate the questionnaire into Turkish. Reliability was assessed by internal consistency of the questionnaire reporting Cronbach’s α coefficient, test–retest reliability that was assessed with the intraclass correlation between instrument scores over time and with the Spearman–Brown coefficient as a variant of split-half reliability. Validity was examined by correlation of the ICQ with the scores of the SF-36 and its eight domains. Eighty-four patients (mean age, 60.7 ± 7.3 years; male, 57%) were given the ICQ and a final completion rate of 98.8% (83 patients) was reached. The mean total ICQ score was 39.1 ± 21.8 (SD) (0–100) for the first application of the questionnaire. Thirty patients out of the eligible 83 completed the questionnaire at two time points with a 1-day interval. For the retest, the total ICQ score was 40.6 ± 26.1 (4.7–97.2). The total SF-36 score of all the study patients was 33.8 ± 20.7 (3.0–81.0). Cronbach’s α was 0.95; the Spearman–Brown coefficient was 0.92; and the intraclass correlation coefficient for the two measurements was 0.91. For the total score and for the scores of domains except the emotional role domain, the correlations were high and all the correlations were statistically significant. In conclusion, the Turkish version of the ICQ, which is a disease-specific, self-administered, and practical instrument, is reliable and valid. We recommend its use to assess the effect of IC on the quality of life of patients in clinical trials and in daily clinical practice.

Does the Circadian Rhythm of Melatonin Affect Ischemia-Reperfusion Injury after Coronary Artery Bypass Grafting?

BACKGROUND Melatonin is a potent scavenger of free radicals and an antioxidant. We studied the relationship between the protective effect of melatonin against ischemia-reperfusion injury (IRI) during cardiopulmonary bypass, the plasma level of melatonin, and the time of surgery. METHODS Forty patients who were to undergo elective coronary artery bypass grafting (CABG) were divided into 2 groups, those who underwent their operations at 8 AM (group I; n = 20) and those who underwent their operations at 1 PM (group II; n = 20). The operations were carried out by the same surgical team and with the same standard surgical technique. Blood samples were collected before the operation (T1), when the aortic cross-clamp was removed (T2), and at 4 hours (T3) and 24 hours (T4) after the operation. RESULTS Preoperative plasma levels of melatonin were substantially higher in group I than in group II. Intraoperative and postoperative melatonin levels were also significantly higher in patients who underwent their operations in the morning. The 2 groups had similar preoperative levels of intercellular adhesion molecule 1 and interleukin 8; however, intraoperative and postoperative values were lower in group I for all samples. This difference was statistically significant for both markers. Plasma levels of lactate dehydrogenase were significantly lower in group I. The 2 groups had similar aortic cross-clamp and cardiopulmonary bypass times. Preoperative and postoperative troponin I levels were lower in group I than in group II, but these differences were not statistically significant. The 2 groups showed no significant differences in plasma creatine kinase MB levels for either preoperative or postoperative measurements. CONCLUSION High plasma levels of melatonin may be directly related to low levels of IRI markers. Melatonin may have a protective effect against IRI in CABG. This effect seems to be directly correlated with the plasma levels of melatonin and inversely related with light. If melatonin protects myocardium from IRI, additional studies may be planned for the preoperative use of melatonin in patients with coronary artery disease to improve myocardial protection.

Perioperative Type I Aortic Dissection during Conventional Coronary Artery Bypass Surgery: Risk Factors and Management

OBJECTIVES Perioperative iatrogenic type I aortic dissection (PIAD) is a rare but potentially fatal complication of conventional coronary artery bypass surgery (CCABG). Prompt recognition and repair of PIAD may significantly improve outcomes. METHODS We reviewed the hospital records of patients with PIAD occurring as a complication of CCABG at Siyami Ersek Thoracic and Cardiovascular Surgery Center from January 2001 through June 2007. During this period, 10,130 CCABG were performed and 21 patients (0.20%) with PIAD were identified. We compared variables for these 21 patients with 603 patients without PIAD (control group). RESULTS PIAD occurred intraoperatively in 19 patients (90%) and during the early postoperative period (first 6 hours) in 2 patients (10%) who underwent CCABG. Dissections were noticed after removal of the aortic crossclamp in 11 patients, during aortic cannulation in 3 patients, and after removal of the partial-occlusion clamp in 5 patients. Patients with and without PIAD differed significantly in regard to sex (P = .05), history of hypertension (P = .001), and history of severe concomitant peripheral arterial disease (PAD) (P = .001). The diameter of the aorta was significantly wider in patients with PIAD. (3.83 +/- 0.9 vs 2.93 +/- 0.46 cm, P = .019). The occurrence of high cardiopulmonary bypass (CPB) pressure (>==120 mmHg) was significantly higher in the PIAD patients than the non-PIAD patients (28.6% vs 3.3%, P = .0001). Seven PIAD patients (33.3%) died preoperatively and 3 (14.2%) died postoperatively. CONCLUSION PIAD is frequently fatal. Risk factors for PIAD during or after CCABG include female sex, history of PAD and hypertension, increased aortic diameter, and high CPB pressure.

Unusual Metastasis of the Papillary Thyroid Adenocarcinoma

Floating thrombus in the ascending aorta is rare and its association with papillary thyroid adenocarcinoma has not been documented. We report a case of a 64-year-old man who was referred to our emergency unit because of suspected type A aortic dissection. Computerized tomographic and transthoracic echocardiographic scans revealed a floating thrombus in the aneurysmatic ascending aorta. The thrombus was removed with the dilated aorta. Although the aortic wall was macroscopically normal, histologic examination revealed metastatic papillary adenocarcinoma.

Comparison of unilateral antegrade cerebral perfusion at 16 degrees C and 22 degrees C systemic temperature.

OBJECTIVES Unilateral antegrade cerebral perfusion can be performed with minimal manipulations to arch arteries, but whether it provides adequate brain perfusion remains unclear. Some authors believe that this technique can be inadequate without deep hypothermia. We investigated the reliability of unilateral cerebral perfusion at 22 degrees C hypothermia and the advantages of avoiding deep hypothermia. METHODS Study participants were 55 patients who underwent surgery with unilateral cerebral perfusion. Patients were divided into 2 groups; 18 patients underwent surgery at 16 degrees C hypothermia (group I) and 37 patients at 22 degrees C hypothermia (group II). The mean age of the patients was 59 +/- 10 years in group I and 55 +/- 14 years in group II. Supracoronary ascending aorta replacement was performed in 25 and hemiarch replacement in 15 patients. Nine patients underwent surgery for a Bentall procedure. Total arch replacement was performed in 4 patients and total thoracic aorta replacement in 2 patients. RESULTS The hospital mortality was 11% in group I and 5.4% in group II (P = .59). Transient neurologic deficits were not detected in any of the patients. The rate of permanent neurologic deficits was 5.9% in group I and 2.8% in group II (P = .54). Although mean aortic cross-clamp and antegrade cerebral perfusion times were not significantly different, mean cardiopulmonary bypass time was longer in group I than group II (174 +/- 38 vs 142 +/- 37 minutes, P = .005). Postoperative bleeding, blood product usage, serum creatinine and hepatic enzyme level changes, inotrope usage, and arrhythmia occurrence were not different between the 2 groups. Mean mechanical ventilation time was longer in group I than group II (24 +/- 17 vs 16 +/- 6 hours, P = .02). CONCLUSIONS Unilateral antegrade cerebral perfusion at 22 degrees C systemic hypothermia appears to be safe and reliable for brain protection. Advantages of this technique are avoidance of deep hypothermia and reduced cardiopulmonary bypass and mechanical ventilation times in patients undergoing aortic surgery.

Coronary Arteriovenous Fistulas in Adult Patients: Surgical Management and Outcomes

Objective The aim of this study was to describe the demographic, clinical and anatomic characteristics of coronary arteriovenous fistulas in adult patients who underwent open cardiac surgery and to review surgical management and outcomes. Methods Twenty-one adult patients (12 female, 9 male; mean age: 56.1±7.9 years) who underwent surgical treatment for coronary arteriovenous fistulas were retrospectively included in this study. Coronary angiography, chest X-ray, electrocardiography and transthoracic echocardiography were preoperatively performed in all patients. Demographic and clinical data were also collected. Postoperative courses of all patients were monitored and postoperative complications were noted. Results A total of 25 coronary arteriovenous fistulas were detected in 21 patients; the fistulas originated mainly from left anterior descending artery (n=9, 42.8%). Four (19.4%) patients had bilateral fistulas originating from both left anterior descending and right coronary artery. The main drainage site of coronary arteriovenous fistulas was the pulmonary artery (n=18, 85.7%). Twelve (57.1%) patients had isolated coronary arteriovenous fistulas and 4 (19.4%), concomitant coronary artery disease. Twenty (95.3%) of all patients were symptomatic. Seventeen patients were operated on with and 4 without cardiopulmonary bypass. There was no mortality. Three patients had postoperative atrial fibrillation. One patient had pericardial effusion causing cardiac tamponade who underwent reoperation. Conclusion The decision of surgical management should be made on the size and the anatomical location of coronary arteriovenous fistulas and concomitant cardiac comorbidities. Surgical closure with ligation of coronary arteriovenous fistulas can be performed easily with on-pump or off-pump coronary artery bypass grafting, even in asymptomatic patients to prevent fistula related complications with very low risk of mortality and morbidity.