Sándor Szabados

Expression of CD97 and Adhesion Molecules on Circulating Leukocytes in Patients Undergoing Coronary Artery Bypass Surgery

Objective: Leukocyte activation is thought to be responsible for the adverse effects and postoperative complications following cardiopulmonary bypass (CPB). A novel cell surface molecule, CD97, is a sensitive marker of leukocyte and primary lymphocyte activation. The present study aimed to determine the activation of different leukocyte subsets by comparing the expression of CD97 and adhesion molecules (CD11, CD18) in patients receiving coronary surgery with or without CPB. Methods: 30 patients were enrolled and scheduled for coronary bypass surgery under CPB (20 patients, group A) and with off-pump (OP) operation (10 patients, group B). Blood samples were taken before and during surgery, and over the following first week. Results: Here, we report an early decrease in CD97 expression of granulocytes (PMN) and monocytes (MC) followed by an intensive increase reaching the maximum on postoperative days 2 and 3 in patients operated with CPB. The rate of active CD97-positive lymphocytes showed a marked, gradual increase until postoperative day 3 and remained elevated up to day 7 after CPB. OP surgery resulted in moderate alteration in the presence of CD97 on PMN, MC and lymphocytes. The expression of adhesion molecules was similar to CD97 in all leukocyte subsets. Conclusion: The findings about CD97 expression suggest considerable leukocyte activation following coronary bypass with CPB compared to OP surgery. The collected data show that the lymphocytes are highly activated and involved in leukocyte sequestration after CPB. Moreover, the importance of CD97 in CPB-related inflammatory response can be stated.

The effect of clopidogrel besylate and clopidogrel hydrogensulfate on platelet aggregation in patients with coronary artery disease: a retrospective study.

BACKGROUND Recently several alternative forms of the original clopidogrel hydrogensulfate (CHS) were spread worldwide. A large amount of such drugs turned out to be clopidogrel besylate (CB). Only three studies, involving healthy volunteers, investigated the antiplatelet effect of CB, whereas its attribute remained unexplored in the case of patients with cardiovascular diseases. This retrospective study aimed to evaluate the difference between the antiplatelet effects of two clopidogrel formulas, CHS and CB, on patients with coronary artery diseases. METHODS Data of 150 patients with previous CHS treatment were investigated. According to the documentations, the CHS therapy was shifted to CB. 94 patients of the selected population received dual antiplatelet therapy, clopidogrel and aspirin. The antiplatelet effects of CHS and CB were compared by ADP induced platelet aggregation measurements using light transmission aggregometry. RESULTS Irrespective of the therapeutic combinations the performed statistical investigations failed to show significant difference (p=0.30) between the effect of CB (AGGmax(CB): 27.6±13.7%) or CHS (AGGmax(CHS): 29.0±15.3%) on the ADP induced platelet aggregation. Insignificant deviations were found in both forms of clopidogrel salts, either in the lack (AGGmax(CB) : 32.5±14,2%; AGGmax(CHS): 34,0±16,1%; p=0,29) or in the presence of aspirin (AGGmax(CB): 24.7±12,5%; AGGmax(CHS): 26,0±14,1%; p=0,31). CONCLUSION Our results indicated that both CB and CHS had an identical inhibitory effect on ADP induced platelet aggregation in patients with cardiovascular diseases. Moreover their efficiency showed no overall significant difference in the case of dual antiplatelet therapy with aspirin as well. However there might be an inter- and intraindividual variability between the two clopidogrel formulas.

Ectopic pancreas tissue appearing in a mediastinal cyst.

Heterotopia of pancreatic tissue is a common developmental anomaly. Although ectopic pancreatic tissue is mostly found in the gastrointestinal tract, localization in the mediastinum is extremely rare. We report a 32-year-old male patient who had an urgent thoracotomy two years ago due to a thoracic surgery. During the thoracotomy fragments of a partly necrotic cystic mass in the right thorax were removed and decortication was performed. Two years later the patient was hospitalized again because of haemoptoe and atypical chest pain. A residual cystic mass was detected between the right hilum and the ascending aorta connecting to the pericardium, the superior vena cava and the aorta on the chest CT. After the operation a mediastinal cyst was diagnosed, with a pancreatic tissue by histology.

Effects of coronary revascularization with or without cardiopulmonary bypass on plasma levels of asymmetric dimethylarginine

ObjectivesWe measured and compared serum asymmetric dimethylarginine (ADMA), symmetric dimethylarginine (SDMA), and L-arginine levels in patients undergoing coronary artery revascularization. MethodsTwo groups of patients with coronary artery disease were subjected to coronary artery bypass graft surgery (CABG) with cardiopulmonary bypass (CPB; n=20) or with off-pump CABG surgery (OPCABG; n=21). Blood samples for measurements of ADMA, SDMA, and L-arginine were withdrawn and determined by liquid chromatography–tandem mass spectrometry from the coronary sinus (CS) and from the peripheral vein. ResultsOn the basis of the intraoperative (CS) samples, ADMA levels rose in the CPB group (F=0.416, P<0.685 and F=14.751, P<0.001 for OPCABG and CPB groups, respectively). A similar significant increase of ADMA was observed in the peripheral blood (F=30.738, P<0.001) during CPB, whereas ADMA levels remained unchanged during OPCABG. The time course of L-arginine levels was significantly different in the blood samples from CS (F=3.255, P<0.05), when compared with samples from the peripheral blood (F=3.255, P<0.05). The values of the L-arginine/ADMA ratio were significantly higher in the OPCABG group at baseline and on the first postoperative day compared with the results of the CPB group (178.29±11.56 vs. 136.28±13.72 and 129.43±7.08 vs. 106.8±6.9 for OPCABG and CPB groups, respectively). ConclusionPlasma levels of ADMA, SDMA, L-arginine, and L-arginine/ADMA ratio are reliable and feasible markers of an early ischemia-reperfusion injury. During CPB operation, the plasma concentration of ADMA increased significantly and remained elevated until the first postoperative day due to extensive ischemia-reperfusion injury caused by CPB.

Elevated levels of asymmetric dimethylarginine (ADMA) in the pericardial fluid of cardiac patients correlate with cardiac hypertrophy

Background Pericardial fluid (PF) contains several biologically active substances, which may provide information regarding the cardiac conditions. Nitric oxide (NO) has been implicated in cardiac remodeling. We hypothesized that L-arginine (L-Arg) precursor of NO-synthase (NOS) and asymmetric dimethylarginine (ADMA), an inhibitor of NOS, are present in PF of cardiac patients and their altered levels may contribute to altered cardiac morphology. Methods L-Arg and ADMA concentrations in plasma and PF, and echocardiographic parameters of patients undergoing coronary artery bypass graft (CABG, n = 28) or valve replacement (VR, n = 25) were determined. Results We have found LV hypertrophy in 35.7% of CABG, and 80% of VR patients. In all groups, plasma and PF L-Arg levels were higher than that of ADMA. Plasma L-Arg level was higher in CABG than VR (75.7±4.6 μmol/L vs. 58.1±4.9 μmol/L, p = 0.011), whereas PF ADMA level was higher in VR than CABG (0.9±0.0 μmol/L vs. 0.7±0.0 μmol/L, p = 0.009). L-Arg/ADMA ratio was lower in the VR than CABG (VRplasma: 76.1±6.6 vs. CABGplasma: 125.4±10.7, p = 0.004; VRPF: 81.7±4.8 vs. CABGPF: 110.4±7.2, p = 0.009). There was a positive correlation between plasma L-Arg and ADMA in CABG (r = 0.539, p = 0.015); and plasma and PF L-Arg in CABG (r = 0.357, p = 0.031); and plasma and PF ADMA in VR (r = 0.529, p = 0.003); and PF L-Arg and ADMA in both CABG and VR (CABG: r = 0.468, p = 0.006; VR: r = 0.371, p = 0.034). The following echocardiographic parameters were higher in VR compared to CABG: interventricular septum (14.7±0.5 mm vs. 11.9±0.4 mm, p = 0.000); posterior wall thickness (12.6±0.3 mm vs. 11.5±0.2 mm, p = 0.000); left ventricular (LV) mass (318.6±23.5 g vs. 234.6±12.3 g, p = 0.007); right ventricular (RV) (33.9±0.9 cm2 vs. 29.7±0.7 cm2, p = 0.004); right atrial (18.6±1.0 cm2 vs. 15.4±0.6 cm2, p = 0.020); left atrial (19.8±1.0 cm2 vs. 16.9±0.6 cm2, p = 0.033) areas. There was a positive correlation between plasma ADMA and RV area (r = 0.453, p = 0.011); PF ADMA and end-diastolic (r = 0.434, p = 0.015) and systolic diameter of LV (r = 0.487, p = 0.007); and negative correlation between PF ADMA and LV ejection fraction (r = -0.445, p = 0.013) in VR. Conclusion We suggest that elevated levels of ADMA in the PF of patients indicate upregulated RAS and reduced bioavailability of NO, which can contribute to the development of cardiac hypertrophy and remodeling.

Paraganglioma of the aortopulmonary window

Aortopulmonary paraganglioma is a rare tumour of the mediastinum of neural crest origin arising in the chromaffin tissues, making up less than 1% of mediastinal tumours. Unlike pheochromocytomas, they are seldom if ever functional, and clinical presentation is frequently delayed until compression of adjacent structures causing angina or dyspnoea. The only effective treatment …

Incisional negative pressure wound therapy in reconstructive surgery of poststernotomy mediastinitis

The efficacy of negative pressure wound therapy in the treatment of poststernotomy mediastinitis has been revealed in many reports. The present retrospective observational study examined the efficacy of incisional negative pressure wound therapy in the reconstructive surgery of poststernotomy mediastinitis. We retrospectively examined 1034 consecutive patients, who underwent median sternotomy in the period between October 2013 and September 2015. Mediastinitis developed in 21 patients (2%), who subsequently underwent surgical reconstruction. We applied incisional negative pressure wound therapy (iNPWT) after primary closure of the wound over redon drains in ten patients (iNPWT + redon group). In 11 patients, only redons were used (redons only group). We observed the time between the introduction and removal of redon drains, hospital stay until final wound closure and the rate of failure of treatment. Failure of treatment is defined as the need for further surgical reconstruction. In the iNPWT + redon group, the duration of redon drainage therapy was 6·9 ± 5·2 days versus 13·36 ± 11·58 in the redons only group. Hospital stay was 11·4 ± 8·6 versus 101·64 ± 89·2, and failure of treatment was 10% versus 45·5%, respectively. The primary results of this study appear to support the beneficial effect of iNPWT after radical wound reconstruction.

Early post-operative thrombosis of the prosthetic mitral valve in patient with heparin-induced thrombocytopenia

Heparin-induced thrombocytopenia (HIT) is one of the most common immune-mediated adverse drug reactions, with frequencies as high as 2-3% for certain groups of post-cardiac surgery patients. We report on an 50-year-old woman with early post-operative thrombosis of the prosthetic mitral valve due to heparin-induced thrombocytopenia. Non-invasive imaging (two-dimensional transesophageal echocardiography; 2D-TEE) allowed the exact localisation of thrombotic masses and revealed the increase of the mean diastolic mitral gradient. The HIT diagnosis was proved by the clinical scoring system, and with the identification of heparin platelet factor 4-induced antibodies. After the withdrawal of LMWH therapy and the start of intravenous lepirudin treatment, the patients medical condition improved continuously. Follow-up echocardiography showed a step-wise decrease in the severity of the mean diastolic mitral valve gradient and a complete resolution of thrombus formations. Perhaps we may remind ourselves that, whilst HIT is one of the most common immune-mediated adverse drug reactions for certain groups of post-cardiac surgery patients, it can be managed successfully. We would also stress the importance of serial 2D-TEE examinations in the early post-operative period.

Vena cava superior syndrome: surgical treatment of the thrombosis of the superior vena cava after implantation of a hemodialysis catheter – a case report and review of the literature

One of the rare reasons of the non malignant superior vena cava syndrome is the thrombosis of superior vena cava. Obstruction or occlusion of central veins is one of the many complications of the more and more frequently used central venous catheters and pacemaker electrodes. The authors report a case of superior vena cava thrombosis resulting in dialysis catheter insufficiency in case of a young, uraemic, female patient wit Tesio catheter and the surgical treatment of it with the use of cardiopulmonary bypass during the operation. Apropos of this case, the authors outline the causes of malignant, non-malignant and iatrogenic superior vena cava syndrome, furthermore the conservative, surgical and catheter therapy of the syndrome.

Anesthetic Management of Aortic Aneurysm

Careful preoperative evaluation of patients undergoing vascular surgical intervention holds great significance since this group of patients has almost the highest percentage of accompanying diseases with poor outcome. It is well-known that vascular disease – irrespectively of its manifestation – is a generalized disorder, the majority of patients with vascular disease smoke and have chronic pulmonary disease, also suffers from diabetes and hypertension. Hypertension and diabetes are often associated with coronary artery disease which determines the short and long-term survival of vascular procedures. Coronary artery disease is one of the most frequent cause of the perioperative mortality and morbidity (15%). Goldman et al. drew the attention to the frequency of cardiac complication of vascular operations as far back as 1977 and aimed to establish a multi-factorial score index. Based on detailed surveys which covered a large patient population the perioperative incidence of myocardial infarction among patient undergoing vascular surgical procedures is 2,1 – 8,0 %, whilst the mortality is 0,6 – 5,4 %. These examinations did not consider the type of operations – open or endovascular. Beside Goldman’s classic risk index numerous task forces have established their own score system for the assessment of perioperative cardiac risk. All of these highlight the significance of the fact that after being aware of the clinical risk, consultation and mutual decision making of cardiologists, anesthetists and vascular surgeons in evaluation the long-term efficiency and risk ratio is essential. The most important weak point of all score system is the utilization of data derived from patients underwent elective operations. Kertai et al. developed a simplified risk index, which is suitable for the assessment of perioperative mortality of either acute or elective patients undergoing vascular surgical operations. The American College of Cardiologist and the American Heart Association has developed a guideline for the assessment of cardiovascular risk among patients with different diseases who are undergoing non-cardiac surgery. This guideline includes the risk assessment for the patient undergoing vascular surgery. Three categories of cardiac risk have been classified in the guideline, high, intermediate and low. High cardiac risk involves the history of acute coronary syndrome, congestive heart failure, significant arrhythmias and severe heart valve diseases. Among non-cardiac surgeries associated with higher cardiac risk, the acute operations, surgery on extremely old patient, operations of the aorta, prolonged operations, operations with excessive fluid or blood loss are considered to be high-risk while carotid endarterectomy should be considered within