Osman Tiryakioglu

A novel predictor of restenosis and adverse cardiac events: asymmetric dimethylarginine

The aim of this study is to investigate if serum asymmetric dimethylarginine (ADMA) levels can predict restenosis and major adverse cardiac events (MACE) in patients who undergo percutaneous coronary interventions. The most important cause of restenosis following percutaneous coronary intervention is neointimal hyperplasia. Nitric oxide (NO) prevents the neointimal hyperplasia growing. Asymmetric dimethylarginine is a competitive inhibitor of NO synthesis. The effect of ADMA on the restenosis has not yet been investigated. A total of 105 (80 male and 25 female) patients were included in our study. All patients underwent elective percutaneous transluminal coronary angioplasty (PTCA) with bare metal stent implantation or direct stenting for one coronary artery between September 2004 and January 2006. All patients were clinically followed for a period of 6 months, and a control angiography was performed at the end of this period. The probrain natriuretic peptide (pro-BNP), high-sensitivity Creactive protein (hs-CRP), and ADMA levels of the patients were evaluated before the procedure and 6 months afterwards. Biochemical parameters and angiographic features were evaluated in order to determine if they could predict the development of restenosis and MACE by using univariate and multivariate Cox regression analysis. The 65 (61.9%) patients (50 males and 15 females) who had not developed restenosis were designated as Group 1. The 27 (25.7%) patients (21 males and 6 females) who had developed restenosis were designated as Group 2. In terms of predicting the development of restenosis, the presence of diabetes mellitus (hazard ratio [HR]: 2.78; confidence interval [CI]: 1.25–6.20; P = 0.01), type of lesion (HR: 1.89; CI: 1.01–3.55; P = 0.04), form of procedure (HR: 0.30; CI: 0.11–0.81; P = 0.01), and ADMA (HR: 4.08; CI: 1.73–9.62; P = 0.001) were found to be significant in univariate Cox regression analysis. In contrast, only the levels of ADMA were found to be a significant predictor of restenosis in the multivariate Cox regression analysis (HR: 3.02; CI: 1.16–7.84; P = 0.02). The restenosis prediction of ADMA levels continued after excluding the patients with diabetes mellitus in the univariate and multivariate Cox regression analysis (HR: 5.23; CI: 1.99–13.76; P = 0.001 and HR: 5.61; CI: 1.79–17.62; P = 0.003, respectively). Regarding the development of cardiac events, hs-CRP (HR: 1.03; CI: 1.00–1.06; P = 0.01) and ADMA (HR: 17.1; CI: 3.06–95.8; P = 0.001) were found to be significantly correlated with adverse cardiac events in univariate Cox regression analysis, whereas only ADMA levels were significant in the multivariate Cox regression analysis (HR: 2.83; CI: 1.27–6.31; P = 0.01). The levels of ADMA obtained before the procedure predict the development of restenosis and MACE in patients who underwent elective PTCA and bare metal stent procedures.

Hydroxyethyl starch versus Ringer solution in cardiopulmonary bypass prime solutions (a randomized controlled trial)

BackgroundIn our study we compared the Ringer solution, which is the standard prime solution of our department, with the HES (Hydroxyethyl starch) 130-0.4 solution, which can be a potential alternative prime solution with an indispensable material for the cardio-pulmonary bypass applications.Methods140 patients undergoing to CABG (Coronary Artery Bypass Graft surgery) were electively enrolled to the study. 1500 ml Ringer solution + 200 ml mannitol + 60 ml sodium bicarbonate + 150 U/kg heparin was used as a prime solution to start cardiopulmonary by-pass in 70 patients which was defined as group 1. On the other hand, 1500 ml HES 130 - 0.4 + 200 ml mannitol + 60 ml sodium bicarbonate + 150 U/kg heparin was used as a prime solution in 70 patients in group 2.ResultsINR (International Normalized Ratio), urea levels and blood platelet counts were significantly different between the groups. INR level was higher in group 1, while blood urea and creatinine levels and platelet count were higher in group 2 at the end of the 12th and 24nd hours postoperatively (p = 0.001).In this study, it was shown that the usage of HES 130-0.4 as a prime solution did not have negative effect on postoperative INR level, platelet count, the need for transfusion and the amount of drainage, despite the negative opinions that similar solutions caused coagulation disorders. Another interesting result of the study was that blood platelet count at 24th hour was statistically significantly higher in group 2 (p = 0.001).ConclusionHES 130-0.4 solution is an alternative colloidal solution which can be used as the prime solution or as a mixture with the crystalloids in cardio-pulmonary bypass applications.

Magnesium sulphate and amiodarone prophylaxis for prevention of postoperative arrhythmia in coronary by-pass operations.

BackgroundThe aim of this study was to investigate the use of prophylactic magnesium sulphate and amiodarone in treating arrhythmias that may occur following coronary bypass grafting operations.MethodsThe study population consisted of 192 consecutive patients who were undergoing coronary artery bypass grafting (CABG). Sixty-four patients were given 3 g of magnesium sulphate (MgSO4) [20 ml = 24.32 mEq/L Mg+2] in 100 cc of isotonic 0.9% solution over 2 hours intravenously at the following times: 12 hours prior to the operation, immediately following the operation, and on postoperative days 1, 2, and 3 (Group 1). Another group of 64 patients was given a preoperative infusion of amiodarone (1200 mg) on first post-operative day (Group 2). After the operation amiodarone was administered orally at a dose of 600 mg/day. Sixty-four patients in group 3 (control group) had 100 cc. isotonic 0.9% as placebo, during the same time periods.ResultsIn the postoperative period, the magnesium values were significantly higher in Group 1 than in Group 2 for all measurements. The use of amiodarone for total arrhythmia was significantly more effective than prophylactic treatment with magnesium sulphate (p = 0.015). There was no difference between the two drugs in preventing supraventricular arrhythmia, although amiodarone significantly delayed the revealing time of atrial fibrillation (p = 0.026). Ventricular arrhythmia, in the form of ventricular extra systole, was more common in the magnesium prophylaxis group. The two groups showed no significant differences in other operative or postoperative measurements. No side effects of the drugs were observed.ConclusionProphylactic use of magnesium sulphate and amiodarone are both effective at preventing arrhythmia that may occur following coronary by-pass operations. Magnesium sulphate should be used in prophylactic treatment since it may decrease arrhythmia at low doses. If arrhythmia should occur despite this treatment, intervention with amiodarone may be preferable.

Aortic dissection due to sildenafil abuse

This report deals with a 28-year-old male patient, admitted with a type A aortic dissection, potentially related to the use of sildenafil. In the literature, we found only two other potentially sildenafil-related cases of aortic dissections, one type A and one type B. In our patient, a bicuspid aortic valve and an ascending aortic aneurysm were other underlying anomalies that could have led to the aortic dissection.

Effects of Nebivolol on Endothelial Function and Exercise Parameters in Patients with Slow Coronary Flow

Objective Earlier studies have reported that a decrease in exercise capacity might indicate endothelial dysfunction. However, the effects of improvement of endothelial functions on exercise capacity have not been evaluated. The aim of the present study is to investigate the effects of nebivolol on flow-mediated dilatation (FMD), and on the exercise capacities of the patients with slow coronary flow (SCF). Methods The study population included 25 subjects with SCF (Group 1) documented by the thrombolysis in myocardial infarction (TIMI) frame count, and 25 control group (Group 2) subjects with normal coronary angiography, for a total of 50 subjects who underwent coronary angiography due to several indications and had no coronary lesion. The TIMI frame count (TFC) values of the subjects in Group I for left anterior descending artery, right coronary, and circumflex coronary artery were 61.8 ± 30.6, 37.2 ± 17.4, and 34.6 ± 17.4, respectively. All the subjects received nebivolol 5 mg/day. Results At the end of the first month of FMD, the mean exercise duration (MED) and the Duke Scores of the patients with SCF were significantly higher than the baseline values. However, the values by the sixth month did not differ from that at the first month. Although a numerical improvement compared to the baseline values was observed for the subjects in Group 2 by the measurements at the end of the first and the sixth month, this difference was not statistically significant. Conclusions Nebivolol treatment increases FMD in the subjects with SCF. The difference in the exercise parameters of these subjects is particularly dramatic, and such an outcome may indirectly indicate long-term improvement in endothelial function.

The Effect of Iloprost and N-Acetylcysteine on Skeletal Muscle Injury in an Acute Aortic Ischemia-Reperfusion Model: An Experimental Study

Objective. The objective of this study was to examine the effects of iloprost and N-acetylcysteine (NAC) on ischemia-reperfusion (IR) injuries to the gastrocnemius muscle, following the occlusion-reperfusion period in the abdominal aorta of rats. Materials and Methods. Forty male Sprague-Dawley rats were randomly divided into four equal groups. Group 1: control group. Group 2 (IR): aorta was occluded. The clamp was removed after 1 hour of ischemia. Blood samples and muscle tissue specimens were collected following a 2-hour reperfusion period. Group 3 (IR + iloprost): during a 1-hour ischemia period, iloprost infusion was initiated from the jugular catheter. During a 2-hour reperfusion period, the iloprost infusion continued. Group 4 (IR + NAC): similar to the iloprost group. Findings. The mean total oxidant status, CK, and LDH levels were highest in Group 2 and lowest in Group 1. The levels of these parameters in Group 3 and Group 4 were lower compared to Group 2 and higher compared to Group 1 (P < 0.05). The histopathological examination showed that Group 3 and Group 4, compared to Group 2, had preserved appearance with respect to hemorrhage, necrosis, loss of nuclei, infiltration, and similar parameters. Conclusion. Iloprost and NAC are effective against ischemia-reperfusion injury and decrease ischemia-related tissue injury.

Agenesis of the mitral posterior leaflet in elderly.

Congenital mitral valve regurgitation is a rare disease that is found in infancy and childhood, and sometimes in elderly people. In the case presented, mitral regurgitation that was tolerated well until the sixth decade of life is reported. A 62-year-old male suffering from dyspnea was referred to our hospital. Transthoracic echocardiographic examination demonstrated severe mitral regurgitation with suspicion of agenesis of the posterior leaflet with a long, mobile anterior leaflet. A transesophageal echocardiogram and surgical evaluation verified agenesis of the posterior mitral valve. The patient was successfully treated using mitral valve replacement, and no complications occurred.

Unilayer Closure of Saphenous Vein Incision Lines is Better than Bilayer Closure

Objective: To examine early results in patients with incision lines closed only along the skin and subcutaneous tissue after removal of the great saphenous vein during coronary artery bypass surgery. Materials and Methods: We enrolled 82 patients who underwent elective operations in our clinic between December 2008 and April 2009. The patients had similar demographic characteristics, and the method of incision closure was chosen randomly. Three patients were excluded due to in-hospital mortality. The saphenous incision lines were closed using continuous skin sutures in 41 patients (Group 1) or using continuous subcutaneous sutures followed by continuous skin sutures in 38 patients (Group 2). Patients were followed every day that they were in the hospital, in the first week after being discharged, and at the end of the second month after discharge. The incision lines were evaluated for hematomas, infection, edema, pain and numbness. Results: During the follow-up performed in-hospital and in the first week after discharge, infection, edema and numbness were observed significantly more often in Group 2 than in Group 1. Hematoma was observed more often in Group 1, and pain was observed more often in Group 2, but neither of these findings reached statistical significance. During the follow-up at the end of the second month after discharge, infection, edema, and numbness were observed significantly more frequently in Group 2. Conclusion: In patients undergoing saphenous removal using standard procedures, it is sufficient to close the incision line using only skin sutures.

Posttraumatic true aneurysm of the axillary artery following blunt trauma.

The majority of the axillary artery aneurysm cases arise as pseudoaneurysms secondary to blunt or iatrogenic trauma. Isolated traumatic true axillary artery aneurysm is a relatively unusual disorder and generally occurs with repetitive blunt trauma. A 22-year-old female patient with distal axillary artery true aneurysm due to simple blunt axillothoracic trauma is presented. The aneurysm was excised with subpectoral-axillary approach and saphenous vein graft interposition was applied. Long-term follow-up with the patient was uneventful.

Giant popliteal aneurysm with deep vein thrombosis, foot drop and arteriomegali

Popliteal artery aneurysms are the most common peripheral arterial aneurysms and are the second most common aneurysm after abdominal aortic aneurysms. Popliteal artery aneurysm affects mostly elderly men and atherosclerosis plays the major role in the aetiology of the disease. The management of popliteal artery aneurysms requires great care. Popliteal aneurysms are asymptomatic or otherwise present with intermittent claudication, compression symptoms in the popliteal fossa, distal embolisation and, rarely, rupture. We present a patient with a remarkably large popliteal aneurysm of 8×11 cm presenting as a popliteal swelling with foot drop and deep vein thrombosis and limb ischaemia. According to our thorough search of literature printed in English, it is one of the largest reported popliteal aneurysms with arteriomegaly, and its co-existing symptoms are unusual. The diagnostic investigations and treatment are presented.