Serdar Ener

Effect of low-dose methyl prednisolone on serum cytokine levels following extracorporeal circulation:

The systemic inflammatory response to cardiopulmonary bypass (CPB) is associated with increased production of cytokines. This systemic inflammatory response characterized by the activation of interleukin-6 (IL-6) and interleukin-8 (IL-8) during and after CPB is well documented. A prospective, randomized, double-blind study was performed so as to understand the effects of low-dose methyl prednisolone sodium succinate (MPSS) on the circulating levels of serum cytokines and clinical outcome. Twenty patients were randomly divided into two groups on the basis of the administration of low-dose (1 mg/kg) MPSS (n = 10) and placebo (n = 10) into the pump prime solution. All patients were scheduled to undergo a primary elective coronary artery bypass grafting operation. Patients receiving concurrent corticosteroids, salicylates, dipyridamol or anticoagulants were excluded from the study. Other exclusion criteria were concurrent chronic obstructive pulmonary disease, chronic renal failure, insulin-dependent diabetes, congestive cardiac failure, peptic ulcer history, prior cardiac operations, recent (in a one-month period) myocardial infarction and steroid dependency. Mild systemic hypothermia (30-32°C, rectal) was assured during the CPB. Four blood samples were drawn from the radial artery catheter immediately before starting CPB (T1), following protamine administration (T2) and at 24 (T3) and 48 h (T4) after completion of CPB. In each sample, creatine kinase-myocardial band (CK-MB), white blood cell (WBC), IL-6 and IL-8 levels were measured. IL-6 and IL-8 concentrations were measured by enzyme immunoassay and enzyme-linked immunoabsorbant assay methods. Serum IL-6 T2 and serum IL-6 T3 levels were significantly higher than IL-6 T1 levels in both groups (p < 0.001) and (p < 0.01), and there was no significant elevation in serum IL-8 levels in either group. Serum IL-6 levels were significantly higher in the placebo group than in the MPSS group at T3 (p < 0.009). There was no significant difference in CK-MB T1 levels between the groups. Although there was no significant difference between CK-MB T1 and T2 levels in the MPSS group, the CK-MB T2 and CK-MB T3 levels were significantly higher than T1 levels in the placebo group (p < 0.001) and (p < 0.05). There was significant elevation of WBC levels at T2 and T3 in both groups without notable difference between the groups (p < 0.05). This study has shown that low-dose MPSS suppresses CPB-induced inflammatory response. Further clinical studies (on larger and higher risk groups) may reveal more information on relations between morbidity and cytokine levels which may have some predictive value on clinical outcome following CPB.

Off-pump bypass grafting in patients with significant left main coronary artery stenosis

The aim of this study was to investigate and determine whether patients with significant (≧%50) left main coronary artery stenosis could undergo coronary bypass on the beating heart and compare the results to those obtained using the conventional method. Prospectively collected data of patients with significant left main coronary artery disease who had undergone coronary bypass on the beating heart (group A, n = 100) or with the conventional method (group B, n = 100) were evaluated retrospectively. EuroSCORE values, preoperative and operative details, postoperative morbidity and mortality, and early results were compared. Groups were similar in terms of EuroSCORE, demographics, and preoperative variables. Number of distal anastomoses per patient was 3.1 ± 0.9 in the beating heart group while it was 3.3 ± 0.9 in the conventional group (P = 0.09). Patients operated on with the conventional method had higher levels of peak creatine kinase-myocardial band, blood and blood product transfusions, and inotropic requirements, while mechanical ventilation times and hospital stay were longer. The incidence of postoperative atrial fibrillation, mediastinitis, and intra-aortic balloon usage were comparable between the groups. There was no neurological complication in group A whereas five major neurological complications (three transient ischemic attacks, two strokes) occurred in group B (P = 0.06). Thirty-day mortality occurred in one patient in the beating heart group whereas five early deaths were observed in the conventional group (P = 0.21). In significant left main coronary artery stenosis coronary bypass on the beating heart is a safe and effective alternative to the conventional method with the same or better early results. The long-term results need to be evaluated.

Complete Atrioventricular Block due to a Hydatid Cyst Located in the Interventricular Septum: A Case Report

We report a case of complete atrioventricular block and tricuspid valve insufficiency due to a cardiac hydatid cyst located in the interventricular septum that occurred in a 19-year-old male patient. Surgery was carried out with the help of cardiopulmonary bypass. The cyst was excised, and the interventricular septum was closed with an autologous pericardial patch treated with glutaraldehyde. The tricuspid valve insufficiency was repaired with annuloplasty. A dual-chamber epicardial pacemaker was implanted. The postoperative course was uneventful, and the patient was doing well 6 months after discharge. This is the first report of a cardiac hydatidosis case for which the repair of the interventicular septum, tricuspid annulopasty, and permanent pacemaker implantation were performed during the same operation.

The effects of sublingual administration of captopril on parameters of exercise test and neurohormonal activation in patients with stable angina pectoris

A prospective randomized, double-blind, and placebo-controlled study was designed to investigate the effects of sublingual administration of captopril on the parameters of exercise test and neurohormonal activation in patients with stable angina pectoris. A total of 31 patients (28 male, 3 female; mean age 55.4±9.4 years) took part in the study. Coronary angiography and left ventriculography were performed in all cases and the patients were classified according to the ejection fraction (EF). Following sublingual placebo or 25 mg captopril, plasma levels of renin, angiotensin II, norepinephrine, and serum aldosterone levels were measured at rest and maximal exercise. test was performed. Hormone levels were remeasured immediately after the exercise. The same procedure was repeated the next day using captopril or placebo. Sublingual captopril administration increased the time to angina, the time to 1 mm ST depression, maximal exercise capacity, maximal exercise duration and decreased maximal ST depression, maximal systolic blood pressure, and maximal double product (p<0.001–0.01). After the maximal exercise test following captopril, the % difference of angiotensin II, aldosterone, and norepinephrine levels was found to be significant lower and the % difference of the renin level was found to be significantly higher than those of placebo (p<0.001). The effects of sublingual captopril on exercise parameters were additionally assessed in different left ventricular systolic function subgroups. The favorable effects were more prominent in cases with left ventricular systolic dysfunction. There were no adverse effects related to sublingual captopril use. As a result, sublingual administration of captopril improved the parameters of maximal exercise test and suppressed the neurohormonal activation during exercise. We suggest that sublingual captopril may be used effectively before planned daily activities in patients with stable angina pectoris.

Biatrial Approach Provides Better Outcomes in the Surgical Treatment of Cardiac Myxomas

Objective We aimed to present clinical features, surgical approaches, importance of surgical technique and long-term outcomes of our patients with cardiac myxoma who underwent surgery. Methods We retrospectively collected data of patients with cardiac myxoma who underwent surgical resection between February 1990 and November 2014. Biatrial approach is the preferred surgical method in a large proportion of patients that are operated due to left atrial myxoma because it provides wider exposure than the uniatrial approach. To prevent recurrence during surgical resection, a large excision is made so as to include at least 5 mm of normal area from clean tissue around the tumor. Moreover, special attention is paid to the excision that is made as a whole, without digesting the fragment of tumor with gentle dissections. Results Forty-three patients (20 males, mean age of 51.7±8.8 years) were included. Most common symptom was dyspnea (48.8%). Tumor was located in the left atrium in 37 (86%) patients. Resections were achieved via biatrial approach in 34 patients, uniatrial approach in 8 patients, and right atriotomy with right ventriculotomy in 1 patient. One patient died due to low cardiac output syndrome in the early postoperative period. Mean follow-up time was 102.3±66.5 months. Actuarial survival rates were 95%, 92% and 78% at five, 10 and 15 years, respectively. Recurrence was observed in none of the patients during follow-up. Conclusion Although myxomas are benign tumors, due to embolic complications and obstructive signs, they should be treated surgically as soon as possible after diagnosis. To prevent recurrence, especially in cardiac myxomas which are located in left atrium, preferred biatrial approach is suggested for wide resection of the tumor and to avoid residual tumor.