Mustafa Özbaran

Cardiac surgery with cardiopulmonary bypass in patients with chronic renal failure.

OBJECTIVE Renal failure is known to increase the morbidity and mortality in patients undergoing cardiac surgery. The results of heart surgery in patients with non-dialysis-dependent, mild renal insufficiency are not clear. METHODS One hundred nineteen adult patients with chronic renal failure underwent cardiac surgery. Group I consisted of 93 patients who had creatinine levels between 1.6 and 2.5 mg/dL but who were not supported by dialysis. Group II consisted of 18 patients with creatinine levels higher than 2.5 mg/dL who were not supported by dialysis. Group III consisted of 8 patients with end-stage renal disease who were receiving hemodialysis. RESULTS The hospital mortality rates were 11.8%, 33.0%, and 12.5%, respectively. Morbidity was 21.5%, 44.4%, and 75.0%, respectively, in groups I, II, and III. Postoperative hemodialysis was needed in 2 (2.15%) patients from group I and 6 (33%) patients from group II. On multivariable logistic regression analysis, risk factors for mortality were preoperative creatinine level more than 2.5 mg/dL, angina class III-IV, emergency operation, excessive mediastinal hemorrhage, postoperative pulmonary insufficiency, low cardiac output, and rhythm disturbances. Risk factors for morbidity were preoperative creatinine level more than 2.5 mg/dL and postoperative dialysis. CONCLUSIONS Chronic renal failure increases the mortality and morbidity in patients undergoing cardiac surgery. Renal insufficiency with creatinine levels higher than 2.5 mg/dL increases the risk of postoperative dialysis and prolongs the length of hospital stay. Careful preoperative management and intraoperative techniques, such as avoiding low perfusion pressure and using low-dose dopamine, may be useful for a good operative outcome.

Perioperative Risk Factors for Mortality in Patients With Acute Type A Aortic Dissection

BACKGROUND This study was undertaken to identify the perioperative risk factors for death in patients with acute type A aortic dissection (AADA). METHODS Between 1993 and 2001, 108 consecutive patients (86 men; mean age, 53 years) underwent emergent operations for AADA. All patients but 2 underwent replacement of the ascending aorta with an open distal anastomosis during a period of hypothermic circulatory arrest. In addition, 22 patients had hemiarch and 5 had total arch replacement. Aortic root was replaced in 20 and repaired with gelatin-resorcinol-formaldehyde glue in 39 patients; aortic valve was separately replaced in 3, resuspended in 24, and remained untouched in 22 patients. RESULTS Overall in-hospital mortality was 25%. Mortality rate was significantly higher in patients with preoperative dissection complications than in those without (21/36 [58%] vs 6/72 [8%], p < 0.001). In multivariate analysis, predictors of mortality were presence of rupture, renal failure, and intestinal malperfusion, duration of cardiopulmonary bypass > or = 200 minutes, blood loss > or = 500 mL, and transfusion of blood > or = 4 units. Location of the intimal tear, extent of the replacement, type of the aortic root repair, and duration of hypothermic circulatory arrest did not emerge as predictors of mortality. CONCLUSIONS Major determinants of surgical mortality in patients with AADA are preoperative complications. Earlier diagnosis remains essential to improve the survival rate.

Ectopic mediastinal pancreas.

Ectopic localisation of the pancreas is not an uncommon entity, but it is mostly seen in the gastrointestinal tract. Herein we report a 45-year-old woman with a cyst containing pancreatic tissue in the mediastinum. The English literature reveals only three previous cases of this extremely rare localisation of the pancreas.

Effect of pulsatile flow during cardiopulmonary bypass on thyroid hormone metabolism

Changes in thyroid hormone levels during and after cardiopulmonary bypass (CPB) are well documented. However, little is known about the effects of pulsatile flow during CPB on thyroid hormone metabolism. To examine the effect of flow pattern, a prospective study was carried out using 30 patients undergoing coronary artery bypass grafting. Fifteen patients had pulsatile flow during CPB and 15, nonpulsatile flow. Serum samples were obtained preoperatively, during bypass, and at 2 and 24 hours postoperatively. Thyroid-stimulating hormone, thyroxine (T4), triiodothyronine (T3), free T4, and free T3 levels were measured by radioimmunoassay. All measured hormone levels except free T4 and thyroid-stimulating hormone decreased after the initiation of CPB. There were no differences in preoperative values between the two groups. However, levels of T3 and free T3 during and after CPB showed a significant difference between the two groups, with a smaller decrease in patients in whom pulsatile flow was used during bypass (p < 0.05). Thyroxine, and thyroid-stimulating hormone free T4 values showed no difference between the two groups at any sampling time. These data provide support for the use of pulsatile flow during CPB to establish a more physiologic state and maintain better thyroid hormone metabolism.

Comparison of Continuous-Flow and Pulsatile-Flow Blood Pumps on Reducing Pulmonary Artery Pressure in Patients With Fixed Pulmonary Hypertension

Pulmonary hypertension (PH) is considered as a risk factor for morbidity and mortality in patients undergoing heart transplantation. Recently, left ventricular assist device (LVAD) implantation has been increasingly used in reducing pulmonary artery pressure (PAP) in patients with PH unresponsive to medical therapy. Herein, we aimed to compare the efficacy of continuous-flow and pulsatile-flow blood pumps on the improvement of PH in mechanical circulatory support patients. Twenty-seven patients with end-stage heart failure who underwent LVAD implantation surgery were enrolled. Fifteen of them (55.6%) had continuous-flow pump (HeartWare Ventricular Assist System, HeartWare, Inc., Miramar, FL, USA), and 12 of them (44.4%) had pulsatile pump (Berlin Heart EXCOR ventricular assist device, Berlin Heart AG, Berlin, Germany). The efficacy of LVADs on the improvement of PH was compared between continuous-flow and pulsatile pumps by the evaluation of systolic PAP, tricuspid annular plane systolic excursion (TAPSE), right ventricular systolic motion (RVSM), right ventricular ejection fraction (RVEF), and grade of tricuspid insufficiency (TI) for each of the study participants. All of the 15 patients who underwent continuous-flow blood pump implantation surgery (Group 1) were male with a mean age of 46.9 ± 11.7 years, and in pulsatile-flow blood pump implanted participants (Group 2), the mean age was 40.6 ± 16.8 years, all of whom were also male (P=0.259). Mean follow-up was 313.7 ± 241.3 days in Group 1 and 448.7 ± 120.7 days in Group 2 (P=0.139). In Group 1, mean preoperative and postoperative systolic PAP were measured as 51.7 ± 12.2 mm Hg and 22.2 ± 3.4 mm Hg, respectively, while those in Group 2 were 54.5 ± 7.5 mm Hg and 33.9 ± 6.4 mm Hg, respectively. A significantly greater decrease in systolic PAP was noticed in patients with continuous-flow blood pumps (P=0.023); however, no statistically significant difference was found when we considered the change in TAPSE between study groups (P=0.112). A statistical significance in the alteration of RVEF, RVSM, and the grade of TI during study visits was not found between the study groups (P=0.472, P=0.887, and P=0.237, respectively). Although the two studied types of LVADs were found to be effective in reducing PAP in heart transplantation candidates with PH, lesser postoperative systolic PAP values were achieved in patients who underwent continuous-flow pump implantation surgery.

Psychiatric evaluation of children and adolescents with left ventricular assist devices.

Objectives To evaluate the psychiatric symptoms of children equipped with a ventricular assist device (VAD) and follow them up for 6 months. With the shortage of donor hearts available for the treatment of end-stage heart failure, VADs have been used to provide temporary treatment until a heart becomes available. VADs provide external sources of power for mechanical circulatory support and are capable of sustaining life over weeks and months. This study provides preliminary details about the psychiatric symptoms and disorders of the first eight children equipped with a VAD in Turkey. Methods Eight pediatric patients who recently underwent VAD implantation, aged 1 to 16 years, were evaluated using the Kiddie Schedule for Affective Disorders and Schizophrenia, Child Behavior Checklist, Children’s Depression Inventory, Beck Depression Inventory, and State-Trait Anxiety Inventory for Children and followed up for 6 months. Results In the first evaluation, five participants had a psychiatric disorder diagnosis. Two patients had adjustment disorder with depressive and anxiety symptoms; one had anxiety disorder, not otherwise specified; and two had major depressive disorder. The anxiety and depressive symptom levels in questionnaires were consistent with psychiatric diagnoses. Two patients had heart transplantation during the follow-up period. Conclusions To determine and treat psychiatric symptoms and disorders at an earlier stage, it is important for children and adolescents with a VAD and those who have undergone heart transplantation to be evaluated by a multidisciplinary consultation liaison team including psychiatrists, psychologists, consultant nurses, and counselors. Abbreviations VAD = ventricular assist device K-SADS = Kiddie Schedule for Affective Disorders and Schizophrenia CBCL = Child Behavior Checklist BDI = Beck Depression Inventory CDI = Children’s Depression Inventory STAI-C = State-Trait Anxiety Inventory for Children MDD = major depressive disorder AD = adjustment disorder PE.I = initial psychiatric evaluation PE.II = second psychiatric evaluation

Ventricular Assist Device as a Bridge to Heart Transplantation in Adults

BACKGROUND Because of the shortage of donor hearts, various ventricular asist devices (VAD) have been used in decompensated patients to prolong patient survival until a suitable heart becomes available. In this paper, we present our single-center report of adult patients in whom bridging was used with VAD. METHODS We performed a retrospective review of 14 adult patients who underwent heart transplantation after insertion of a long-term VAD. The study spans from February 2006 until September 2010. The mean patient age was 44.28 ± 11.06 years. We used the Berlin Heart EXCOR VADs (n = 11; Berlin Heart AG Berlin, Germany), or the Berlin Heart Incor (n = 2), or the Abiomed AB500 (n = 1). Preimplantation status of the subjects were critical cardiogenic shock (n = 6), deterioration on inotropes (n = 3), or stable but inotrope-dependent (n = 5). RESULTS Mean VAD support time was 153.71 days (range, 25-517). Major adverse events during VAD support included reexploration for bleeding (n = 3; 21.4%), neurologic events (n = 2; 14.3%), left VAD-related infection (n = 2; 14.3%), pneumonia (n = 1; 14.3%), or primary device failure (n = 1; 7.1%). One (7.1%) patient showed evidence of human leukocyte antigen sensitization. There were 2 deaths (14.3%) over a mean of 324 days follow-up after heart transplantation: One due to biventricular failure in the early postoperative period and the other, at 69 days from pneumonia. Rejection was observed in 2 patients who had International Society for Heart and Lung Transplantation grade 2R without hemodynamic deterioration. In our series, the 1-year mortality was 14.4% among heart transplantations without VAD implantation and 14.2% among the bridge-to-transplantation group. CONCLUSION We conclude that VAD implantation improved end-organ function before heart transplantation in critically ill patients.

Determinants of Early Mortality and Neurological Morbidity in Aortic Operations Performed Under Circulatory Arrest

Abstract Objective: Aneurysms and dissections of the thoracic aorta continue to present a surgical challenge and their incidence is increasing in recent years. The mortality rate of surgical treatment is still higher than those of other cardiovascular operations. Neurological injury is the most feared complication resulting from repair of these lesions. This study aims to determine the factors that influence the neurological outcome and mortality after thoracic aortic operations. Methods: During the period from November 1993 through May 1999, 144 patients were operated on for conditions involving the ascending aorta and/or aortic arch. Ninety‐five (66.0%) were operated for aortic dissection and 49 (34.0%) were for aortic aneurysms. Sixty‐two patients (43.1%) had replacement of ascending aorta with distal open technique; 82 patients (56.9%) had hemiarch or total arch replacement or repair of the distal arch. Results: Twenty‐seven (18.7%) early deaths occurred. New stroke occurred in two patients (1.4%) and temporary neurological dysfunction in nine patients (6.3%). Deep hypothermic circulatory arrest with retrograde cerebral perfusion was used in all patients. On multivariate logistic regression analysis, risk factors for mortality were chronic renal failure, preoperative organ malperfusion, rupture, total circulatory arrest time > 60 minutes, postoperative acute renal failure, postoperative low cardiac output, sepsis, and multiple organ failure. Risk factors for neurological morbidity were preoperative chronic renal failure, preoperative hemodynamic instability, postoperative low cardiac output, and pulmonary complications. Conclusions: Hypothermic circulatory arrest with retrograde cerebral perfusion was not an independent predictor of neurological morbidity on multivariate analysis, even if the arrest period was more than 60 minutes. Lengths of circulatory arrest periods and clinical presentations of the patients are important determinants of mortality.

Effect of Aortic Valve Movements on Gastrointestinal Bleeding That Occured in Continuous Flow Left Ventricular Assist Device Patients

BACKGROUND Gastrointestinal (GI) bleeding is one of the recently reported complications with continuous flow left ventricular assist devices (LVAD). The pathophysiology and etiology are unclear. We sought to describe the relationship between aortic valve movements and GI bleeding among patients with a new generation of LVAD. METHODS We evaluated the data of 30 patients who underwent LVAD (HeartWare VAD) implantation from December 2010 to September 2012. The most common etiologic diagnosis was dilated cardiomyopathy. Patients were considered to show GI bleeding if they had hematemesis, melena, or hematochezia. RESULTS Among 3 patients, 2 displayed upper GI bleeding and 1 had lower GI bleeding based on endoscopic and colononoscopic examinations. Pathological reports showed arteriovenous malformations in patients diagnosed with upper GI bleeding. The absence of aortic valve movements and a history of previous GI bleeding were significant risk factors (P = .021 and P = .007, respectively). CONCLUSION In addition to aortic valve movements, we believe that a GI bleeding history was an equally important factor predisposing to this complication.

Comparison of heart transplantation patients with ischemic and idiopathic dilated cardiomyopathy.

OBJECTIVE We retrospectively analyzed our data to compare preoperative demographic, laboratory, echocardiographic, hemodynamic findings mortality and survival rates of heart transplantation patients with ischemic (ICM) and idiopathic dilated (IDCM) cardiomyopathy. METHODS The data of 144 patients transplanted from February 1998 to January 2011 were analyzed. 38 patients with ischemic ICM and 86 patients with IDCM were compared. RESULTS Recipient age, preoperative creatinine, recipient body mass index, intraoperative cross-clamp time, donor male sex ratio, recipient male sex ratio, hyperlipidemia ratio, and previous nitrate use were significantly higher and left ventricular end systolic diameter significantly lower in patients with ICM. Major causes of death after heart transplantation were infections (31.9%), right ventricle failure (14.8%), and sudden cardiac death (14.8%). Causes of death were not different between the groups. Overall mortality in the entire population was 37.9% (47/124), and it was not different between the groups (39.5% vs 37.2%; P=.48). Early mortality (<30 days) rate was 11.2% (14/124), late mortality rate was 26.6% (33/124), and no statistically significant difference was observed between the groups. Survival analysis showed that ICM patients were not associated with worse survival compared with IDCM (71.1% vs 81.1% after 1 year, 68.1% vs 73.0% at 2 years, and 54.2% vs 62.3% at 5 years; log rank=0.57). Multivariate analysis showed that the only predictor of mortality was preoperative urea level and that heart failure etiology was not a predictor of this end point. CONCLUSIONS Patients with ICM had similar survival and mortality rate compared with IDCM.