Sait Aslamaci

Systemic Inflammatory Response Related to Cardiopulmonary Bypass and Its Modification by Methyl Prednisolone: High Dose Versus Low Dose

AbstractThe objective of our study was to investigate the safety and efficacy of high-dose methyl prednisolone (MP) in modifying the systemic inflammatory response (SIR) to cardiopulmonary bypass (CPB) and to compare its efficacy with low-dose MP in children undergoing cardiac surgery for congenital heart disease. Thirty children with congenital heart disease undergoing CPB were randomly assigned to two groups: group 1 (n = 15) received 30 mg/kg MP by an intravenous infusion for 30 minutes and group 2 (n = 15) received 2 mg/kg intravenously, before the onset of CPB. Postoperative clinical parameters were recorded, and serum interleukin (IL)-6 and 8 levels, acute phase reactants, and blood biochemistry were determined serially for both groups. In both groups plasma IL-6 and 8 levels were elevated above the preoperative levels at 2 and 24 hours after declamping. The peak levels were obtained at 2-hour samples. The difference between the two groups in terms of postoperative IL-6 and 8 levels was not statistically significant. C-reactive protein (CRP) levels and polymorphonuclear leukocyte counts, postoperative core temperature, duration of mechanical ventilation, period of stay in intensive care unit, oxygenation indices, and biochemical parameters of patients did not significantly differ in the two groups. Only 1 patient in group 1 had elevated liver enzymes, blood urea nitrogen, and creatinine in the postoperative period. No significant complications were observed due to treatment with high-dose MP. Although postoperative IL and CRP levels indicated a SIR in our patients, the clinical picture was apparently affected in only 1 patient and she was in the high-dose MP group. CPB initiates a SIR that is associated with an increase in neutrophil count, CRP, and IL-6 and 8 levels. High-dose (30 mg/kg) MP was not superior to low-dose (2 mg/kg) in blunting the SIR to CPB in pediatric patients undergoing open-heart surgery.

Atrial fibrillation after coronary artery bypass surgery: P wave signal averaged ECG, clinical and angiographic variables in risk assessment.

BACKGROUND Atrial fibrillation (AF) is a commonly encountered arrhythmia and occurs in up to 40% of patients after coronary artery bypass surgery (CABG). The preoperative signal averaged ECG (SAECG) P wave may be useful indicator of AF after CABG. We prospectively analyzed the predictive value of SAECG P wave compared to clinical variables. METHODS Fifty-three patients with coronary artery disease undergoing first elective CABG were enrolled. All patients had P wave specific SAECG, standard 12 lead ECG, ejection fraction and left atrial posteroanterior diameter from the echocardiogram within the 24 h before surgery. From the SAECG P wave, filtered P wave duration was measured. Lead II P wave duration, left atrial enlargement and left ventricular hypertrophy were determined from standard ECG. Patients were continuously monitored during their postoperative period and serial ECGs were taken. RESULTS During an observation period of up to 16 days, 19 (35.8%) patients developed AF 2.8+/-1.3 days after CABG. Patients with AF more often had left atrial enlargement (LAE) on ECG (P = 0.041) and right coronary artery (RCA) lesion (P = 0.0034). The filtered P wave duration on the SAECG was significantly longer in the AF patients than those without AF (129.7+/-13.2 ms versus 113.9+/-9.0 ms, P = 0.001). Logistic regression analysis identified independent predictors, estimated adjusted relative risk (95% confidence interval) of AF: with LAE, the relative risk was 2.72 (1.13-5.82), RCA lesion, the relative risk was 3.06 (1.45-6.45) and SAECG P wave duration >122.3 ms, the relative risk was 4.58 (2.11-9.97). The occurrence of AF was predicted by electrocardiographically determined left atrial enlargement with a sensitivity of 36%, specificity of 88%, positive predictive accuracy of 63%, negative predictive accuracy of 71%. If presence of right coronary artery lesion was evaluated these values were 63%, 79%, 63%, 79% subsequently. P wave duration >122.3 ms had a sensitivity of 68%, specificity of 88%, positive predictive accuracy of 76%, negative predictive accuracy of 83%. If both P wave >122.3 ms and presence of right coronary artery lesion were combined, these values were 47%, 94%, 81%, 76% subsequently. CONCLUSION The predictors of AF after CABG were left atrial enlargement on standard 12 lead ECG, RCA lesion and SAECG P wave duration. Among these predictors, SAECG P wave duration was the best predictor of AF after CABG.

Diaphragmatic paralysis after cardiac surgery in children: incidence, prognosis and surgical management.

Diaphragmatic paralysis (DP) after cardiac surgery is an important complication especially in infants. We analyzed the incidence, clinical course, surgical management and follow up of the patients with DP, retrospectively. Between 1996 and 2005, 3,071 patients underwent cardiac surgery. Total number of patients with DP was 152 (4.9%). Out of 152 patients, 42 were surgically treated with transthoracic diaphragm plication (1.3%). The overall incidence of diaphragm paralysis was higher in correction of tetralogy of Fallot (31.5%), Blaloc–Taussig (B–T) shunt (11.1%) and VSD closure with pulmonary artery patch plasty (11.1). The incidence of DP which require plication was higher in B–T shunt (23.8%) arterial switch (19%) and correction of tetralogy of Fallot (11.9%). Mean and median age at the time of surgery were 17.8±3.6 and 6 months, respectively. Median time from cardiac surgery to surgical plication was 12 days. Indications for plication were repeated reintubations (n=22), failure to wean from ventilator (n=12), recurrent lung infections (n=5) and persistent respiratory distress (n=3). Mortality rate was 19.1%. Being under 1 year of age, pneumonia and plication 10 days after mechanical ventilation were associated with higher incidence mortality (P<0.05). Phrenic nerve injury is a serious complication of cardiac surgery. It is more common after some special procedures. Spontaneous recovery is very rare. Being under 1 year of age, plication after 10 days from the surgery and pneumonia are major risk factors for mortality even in plicated patients. Transthoracic plication is helpful if performed early.

Diabetes decreases mRNA levels of calcium-release channels in human atrial appendage

Patients with chronic diabetes mellitus usually develop reductions in rate and force of cardiac contractions. Since calcium-release channels (ryanodine receptors (RyRs) and inositol 1,4,5-trisphosphate receptors (IP3Rs)) play integral roles in effecting these processes, we rationalize that alterations in their expression may underlie these defects. To test this hypothesis, right atrial appendages were obtained from diabetic (65.0 ± 4.5 years) and nondiabetic (56.2 ± 2.6 years) patients undergoing coronary arterial by-pass grafting and reverse transcription-polymerase chain reactions were used to compare steady state levels of mRNA encoding the three major isoforms of RyRs and IP3Rs. In this study we did not detect either RyR1 or RyR3 in human atrial appendage. When compared with nondiabetic patients, mRNA encoding RyR2 from diabetic patients decreased by 74.2 ± 6.2% (p< 0.01). Diabetes also significantly decreased steady-state levels of mRNA encoding the IP3Rs in human atrial appendage. IP3R1 decreased by 24.2 ± 4.6%, IP3R2 decreased by 63.0 ± 4.6% and IP3R3 decreased by 55.5 ± 6.5%. Since a reduction in steady-state mRNA is usually indicative of a decrease in protein levels, these data suggest that the decrease in chronotropy and inotropy seen in chronic diabetic patients may be due in part to a decrease in expression of calcium-release channels. (Mol Cell Biochem 263: 143-150, 2004).Patients with chronic diabetes mellitus usually develop reductions in rate and force of cardiac contractions. Since calcium-release channels (ryanodine receptors (RyRs) and inositol 1,4,5-trisphosphate receptors (IP3Rs)) play integral roles in effecting these processes, we rationalize that alterations in their expression may underlie these defects. To test this hypothesis, right atrial appendages were obtained from diabetic (65.0 ± 4.5 years) and nondiabetic (56.2 ± 2.6 years) patients undergoing coronary arterial by-pass grafting and reverse transcription-polymerase chain reactions were used to compare steady state levels of mRNA encoding the three major isoforms of RyRs and IP3Rs. In this study we did not detect either RyR1 or RyR3 in human atrial appendage. When compared with nondiabetic patients, mRNA encoding RyR2 from diabetic patients decreased by 74.2 ± 6.2% (p< 0.01). Diabetes also significantly decreased steady-state levels of mRNA encoding the IP3Rs in human atrial appendage. IP3R1 decreased by 24.2 ± 4.6%, IP3R2 decreased by 63.0 ± 4.6% and IP3R3 decreased by 55.5 ± 6.5%. Since a reduction in steady-state mRNA is usually indicative of a decrease in protein levels, these data suggest that the decrease in chronotropy and inotropy seen in chronic diabetic patients may be due in part to a decrease in expression of calcium-release channels. (Mol Cell Biochem 263: 143–150, 2004)

Mitral Valve Replacements in Redo Patients with Previous Mitral Valve Procedures: Mid‐Term Results and Risk Factors for Survival

Abstract  Objective: We aimed to investigate the risk factors for hospital mortality, short (five years) and mid‐term (10 years) survival in patients who underwent mitral valve replacements in redo patients with previous mitral valve procedures. Patients and Methods: Between September 1989 and December 2003, 62 redo patients have undergone mitral valve replacements due to subsequent mitral valve problems. Preoperative, operative, and postoperative data were analyzed retrospectively and evaluated for risk factors affecting hospital mortality, mid‐ and long‐term survival. Results: The hospital mortality was 6.4%. The one‐, five‐, and 10‐year actuarial survival rates were 94%± 2%, 89%± 6%, and 81 ± 9%. New York Heart Association (NYHA) functional class IV, low left ventricular ejection fraction (<35%), increased left ventricular end‐diastolic diameter (LVEDD) > 50 mm, female gender, pulmonary edema, and urgent operations were found to be risk factors in short‐term survival. NYHA functional class IV, low left ventricular ejection fraction, increased LVEDD, and increased left atrial diameter (LA > 60 mm) were risk factors in mid‐term survival. Conclusion: Redo mitral valve surgery with mechanical prosthesis offers encouraging short‐ and mid‐term survival. NYHA functional class IV, low left ventricular ejection fraction, and increased left ventricular diameters were especially associated with increased short‐ and mid‐term mortality. Earlier surgical management before the development of severe heart failure and myocardial dysfunction would improve the results of redo mitral valve surgery.

Alteration of vascular reactivity in diabetic human mammary artery and the effects of thiazolidinediones

Vascular reactivity was investigated in endothelium‐denuded human internal mammary artery (IMA) rings from type 2 diabetic patients. It was also investigated whether insulin sensitizer thiazolidinedione drugs, pioglitazone and rosiglitazone, can directly affect the reactivity of IMA. Using organ bath techniques, cumulative concentration‐response curves to phenylephrine (PE), KCl, cromakalim (CRO) and sodium nitroprusside (SNP) were constructed in diabetic and non‐diabetic IMA rings. Means of maximal responses (% Emax) and pEC50 values (sensitivity) were compared. Emax values and the sensitivity to PE and KCl were increased while KATP‐channel‐mediated relaxations were reduced significantly in diabetic rings compared with non‐diabetic rings (n = 5–12, P < 0.05). No changes were observed for SNP responses (n = 5, P > 0.05). Incubations with pioglitazone (1 and 10 μM) and rosiglitazone (1 and 20 μM), for 30 min, did not affect KATP‐channel‐mediated relaxations (n = 5 each, P > 0.05). Pioglitazone partly inhibited pre‐contractions of PE and KCl at 10 μM, rosiglitazone did not. Vascular dysfunction observed in diabetic IMA may be of specific importance since they are widely used as coronary bypass material. Thiazolidinedione drugs may not worsen arterial dilatation through KATP channels in ischaemic or hypoxic insults in diabetic patients who are prone to such conditions. Pioglitazone has vasorelaxant property in the grafts.

Clinical investigations over 13 years to establish the nature of the cardiac defects in patients having abnormalities of lateralization

INTRODUCTION The first step in diagnosing congenital cardiac malformations is to assess the arrangement of the atrial appendages. In patients with abnormal lateralization of the organs of the body, the arrangement of atrial appendages is neither normal, nor a mirror image of normal. There are 2 categories of abnormal arrangement based on the morphology of the atrial appendices, namely right isomerism and left isomerism, and in almost all instances these are found in the setting of so-called heterotaxy syndromes. OBJECTIVE To evaluate the various congenital cardiac malformations those are associated with abnormalities of lateralization, and to discuss the diagnostic tools, therapeutic options, and outcome for these patients. PATIENTS AND METHODS We studied 134 patients, who had been admitted to our department of paediatric cardiology with known abnormalities of lateralization and congenital cardiac defects between 1990 and 2003. The data relating to each patient was evaluated retrospectively. The arrangement of the atrial appendages was established echocardiographically, and/or angiographically, and/or on the basis of morphologic investigations during the operation. These studies showed that 43 (32.1%) of the patients had right isomerism, and 88 (65.7%) had left isomerism. In 2 (1.5%), there was mirror-imaged arrangement, while in the final patient (0.07%), we were unable to determine sidedness with certainty. The median age at diagnosis was 0.66 years, and the females outnumbered the males in a ratio of 3 to 1. Patients in the 2 isomeric groups were compared with regard to age, cardiac defects, diagnostic tools and outcomes. RESULTS The difference in mean ages of the two groups of patients was statistically significant, those with right isomerism being 1.0 minus or plus 1.5 years, as opposed to those with left isomerism being 3.3 minus or plus 4.7 years (P is less than 0.005). Of the patients with right isomerism, 32 (74.4%) had left-sided, and 11 (25.6%) right-sided hearts, whereas in those with left isomerism, the hearts were left-sided in 65 (73.9%), and right-sided in 21 (23.9%), with 2 (2.2%) positioned in the midline. Extracardiac totally anomalous pulmonary venous connection was more common in those with right isomerism, being found in 13 patients (30.2%) as opposed to 5 patients (5.7%) with left isomerism. In only 8 of those with right isomerism did we find two perforate atrioventricular valves (18.6%), this arrangement being found in 34 (38.6%) of those with left isomerism. Pulmonary atresia and stenosis were present in 40 (93.0%) of those with right isomerism, but also in 41 (46.6%) of the patients with left isomerism. Angiographic and echocardiographic investigations were concordant in about three-quarters of patients with both right and left isomerism. All patients with extracardiac totally anomalous pulmonary venous connection died. Overall, 22 of the patients with right isomerism died (51.2%), as opposed to 20 (22.7%) of those with left isomerism. CONCLUSION Our experience confirms that patients with right isomerism have more complex cardiac defects than those with left isomerism. Overall, the presence of isomerism carries a poor prognosis, the more so for right isomerism, with this related to the complex cardiac abnormalities. In our cohort, extracardiac totally anomalous pulmonary venous connection with pulmonary arterial obstruction was always a fatal combination. The mapping of cardiac and abdominal morphologies is still essential for proper diagnosis of these syndromes, especially in fetal life.

Decreased expression of β1- and β2-adrenoceptors in human diabetic atrial appendage

BackgroundUsing the streptozotocin-induced diabetic rat model, we have recently showed that the expression and function of β1-adrenoreceptor were decreased in the diabetic rat heart. However, the effect of diabetes on expression of β-adrenoreceptors in human cardiac tissue remains undefined. Therefore, the focus of the present study was to investigate the effect of diabetes on mRNA encoding β1- and β2-ARs in human atrial tissues.MethodsRight atrial appendages from five diabetic (mean age 65 ± 4.5; 4 female, 1 male) and five nondiabetic patients (mean age 56.2 ± 2.8; 4 male, 1 female) undergoing coronary artery bypass grafting were collected and assayed using reverse transcriptase-polymerase chain reaction (RT-PCR) for their mRNA content. No patient from these two groups suffered from acute myocardial infarction and/or failure. All diabetic patients received insulin for at least two years and had been diagnosed as diabetics for at least five years.ResultsWhen compared with levels in nondiabetics, steady state levels of mRNA encoding β1-adrenoreceptor decreased by 69.2 ± 7.6 % in diabetic patients while β2-adrenoreceptor mRNA decreased by 32.2 ± 5.5 % (p < 0.001).ConclusionsOur findings show a decreased expression of β1- and β2-adrenoreceptors in human diabetic atrial appendage.

Fenestration Between the Left Atrial Appendage and Left Superior Vena Cava in Kawashima Operation

The benefits of a baffle fenestration in essentially high-risk Fontan patients have been demonstrated. Described here is the use of a new fenestration between the left atrial appendage and the left superior vena cava after Kawashima operation in a patient with a double-outlet right ventricle with hypoplastic left ventricle, left atrial isomerism, bilateral superior vena cavae with no bridging vein, an interrupted inferior vena cava, and continuation of the hemiazygos vein to the left superior vena cava.

The Role of Antiendothelial Cell Antibodies in the Development and Follow-up of Coronary and Peripheral Arterial Diseases

Occlusive lesions in the arterial endothelium are often caused by formation of intimal hyperplasia and fibrinoid necrosis. The objective of this study was to investigate the association between antiendothelial cell antibodies (AECAs) and the development of coronary artery disease (CAD) and peripheral artery disease (PAD). In this study, 94 patients with CAD or PAD and 94 healthy volunteers serving as control subjects were examined. Frozen sections of human umbilical vein endothelial cells and primate smooth muscle cells were used to detect the presence of AECAs, which were found in 52 of 94 patients (55%) and in 15 of 94 controls (16%) (P < .001). Endothelial structure tissue damage is a major factor in arterial diseases. In the present study, a statistically significant relationship was found between AECAs and the development of CAD and PAD. The presence of AECAs has been identified as a risk factor for these diseases. According to this study, AECAs are reliable prognosticators for the development of CAD and PAD. Further studies with large numbers of serum samples are under way.