Suat Canbaz

Electrophysiological evaluation of phrenic nerve injury during cardiac surgery--a prospective, controlled, clinical study.

BackgroundAccording to some reports, left hemidiaphragmatic paralysis due to phrenic nerve injury may occur following cardiac surgery. The purpose of this study was to document the effects on phrenic nerve injury of whole body hypothermia, use of ice-slush around the heart and mammary artery harvesting.MethodsElectrophysiology of phrenic nerves was studied bilaterally in 78 subjects before and three weeks after cardiac or peripheral vascular surgery. In 49 patients, coronary artery bypass grafting (CABG) and heart valve replacement with moderate hypothermic (mean 28°C) cardiopulmonary bypass (CPB) were performed. In the other 29, CABG with beating heart was performed, or, in several cases, peripheral vascular surgery with normothermia.ResultsIn all patients, measurements of bilateral phrenic nerve function were within normal limits before surgery. Three weeks after surgery, left phrenic nerve function was absent in five patients in the CPB and hypothermia group (3 in CABG and 2 in valve replacement). No phrenic nerve dysfunction was observed after surgery in the CABG with beating heart (no CPB) or the peripheral vascular groups. Except in the five patients with left phrenic nerve paralysis, mean phrenic nerve conduction latency time (ms) and amplitude (mV) did not differ statistically before and after surgery in either group (p > 0.05).ConclusionsOur results indicate that CPB with hypothermia and local ice-slush application around the heart play a role in phrenic nerve injury following cardiac surgery. Furthermore, phrenic nerve injury during cardiac surgery occurred in 10.2 % of our patients (CABG with CPB plus valve surgery).

The Role of Inflammation in Atrial Fibrillation following Open Heart Surgery

This study investigated the role of systemic inflammation in the development of atrial fibrillation (AF) after coronary artery bypass grafting (CABG). CABG was performed using cardiopulmonary bypass in 77 patients. Pre-operative AF was present in six patients (7.8%) and post-operative AF developed in 13 (18.3%) of the 71 patients with pre-operative sinus rhythm. Post-operative mediastinal drainage was significantly increased in patients with post-operative AF compared with those with sinus rhythm. Plasma E-selectin, P-selectin and vascular cell adhesion molecule levels were not significantly different between patients with pre- and post-operative sinus rhythm, those with pre-operative sinus rhythm and post-operative AF, and those with pre- and post-operative AF. There were significant differences between pre-and post-operative C-reactive protein, interleukin (IL)-6 and IL-10 levels within all three groups, but no differences in these parameters between the groups. Thus, in all groups there were significant alterations in mediators indicative of systemic inflammation following CABG, but comparisons between the groups revealed no differences predictive of AF.

Thoracic left kidney: a differential diagnostic dilemma for thoracic surgeons

We report a case of left thoracic kidney that was identified after a detailed workup for a left thoracic mass that appeared on a routine chest roentgenogram of a young adult. Intravenous pyelography and angiography clearly identified this rare anomaly. Anatomical features and clinical implications of this condition are presented.

Excision of Aortic Vegetation in Brucella Endocarditis

A 19-year-old man with brucella endocarditis was treated by antimicrobial therapy and surgical excision of vegetation with preservation of the native aortic valve.

Effect of pericardial fluid pro-inflammatory cytokines on hemodynamic parameters.

We investigated the effects of pro-inflammatory cytokines of pericardial fluid on hemodynamic parameters in patients undergoing coronary artery surgery. Seventy-eight patients were included in the study and they were allocated to three groups: group 1, stable angina pectoris (SAP, n = 15); group 2, unstable angina pectoris (USAP, n = 34); group 3, post-myocardial infarction (PMI, n = 29). Pericardial fluid and arterial blood samples were obtained from all patients and interleukin (IL)-1beta, IL-2 receptor, IL-6, IL-8 and tumor necrosis factor-alpha (TNF-alpha) levels were measured. Pericardial IL-1beta concentration (pg/mL) was significantly higher in the USAP group (26.6 +/- 10.9) compared to the SAP (5.0 +/- 0.1) and PMI (5.8 +/- 1.0) groups. IL-2R, IL-6, IL-8 and TNF-alpha concentrations of pericardial fluid were significantly higher than serum in all groups; difference was more prominent in the PMI group compared to the SAP and the USAP groups. Serum IL-1beta concentrations (pg/mL) were significantly higher in the USAP group (21.8 +/- 3.4) compared to the SAP group (5.0 +/- 0.1) and the PMI group (5.4 +/- 1.6). Cardiac index (CI) before opening the pericardial sac was found to be lower in the USAP group (1.6 +/- 0.3 L/min/m2) compared to the SAP (2.2 +/- 0.5 L/min/m2) and the PMI (2.1 +/- 0.5 L/min/m2) groups (p = 0.028 and p = 0.011, respectively). In the USAP group, there was a relationship between reduction of CI and increase of IL-1beta levels in serum and pericardial fluid.

The effects of cardiopulmonary bypass on androgen hormones in coronary artery bypass surgery.

The effects of testosterone on coronary vasomotor regulation have been described by several recent reports. Here we investigated changes in serum androgen levels during and after cardiopulmonary bypass (CPB) in patients who had undergone coronary artery bypass surgery. Serum luteinizing hormone, free testosterone and dihydroepiandrestenedione sulphate (DHEA sulphate) levels were evaluated in 38 male coronary artery bypass surgery patients using a chemical immunoassay technique. All hormone levels were corrected to account for haemodilution. Serum-free testosterone level decreased significantly during weaning from CPB (from 15.7 ± 4.2 nmol/l to 6.2 ± 2.8 nmol/l), and an even greater decrease was observed in the first post-operative day (5.4 ± 3.1 nmol/l). On the seventh post-operative day, free testosterone levels reached a normal value (11.8 ± 5.5 nmol/l), although they were still significantly lower compared with the pre-operative value. There were slight alterations in serum DHEA sulphate levels, although the only significant decrease occurred from the first to the seventh day post-operation (from 4.7 ± 2.2 μmol/l to 3.7 ± 1.8 μmol/l, respectively). Serum luteinizing hormone levels were decreased during weaning from CPB (from 4.8 ± 2.1 mIU/ml to 3.9 ± 1.8 mIU/ml), but increased rapidly to the pre-operative value (5.5 ± 2.5 mIU/ml) at the first post-operative day. These results show that CPB affects serum luteinizing hormone, free testosterone and dihydroepiandrestenedione sulphate levels. The free testosterone level decreases significantly both during and after CPB surgery.

The effects of sildenafil and n-acetylcysteine on ischemia and reperfusion injury in gastrocnemius muscle and femoral artery endothelium.

Purpose We aimed to examine the effects of sildenafil and n-acetylcystein on ischemia/reperfusion injury in femoral artery endothelium and gastrocnemius muscle. Basic methods 32 rats of Sprague-Dawley breed were randomly divided into four groups (n = 8). Median laparotomy was performed, then a 120-minute ischemia was created by microvascular clamping of infrarenal aorta, followed by the release of clamping. In sildenafil group, 1 mg/kg of sildenafil infusion and in the n-acetylcystein group, 100 mg/kg of n-acetylcystein infusion was administered after release of clamps. Blood samples and tissue samples of femoral artery and gastrocnemius muscle were extracted for a histopathological evaluation. Principal findings Serum levels of malondialdehyde in ischemia/reperfusion group (6.16 ± 0.79) were higher compared to the control group (4.69 ± 0.33), whereas a significant decrease was detected in sildenafil (5.17 ± 0.50) and n-acetylcystein (4.96 ± 0.49) groups. Femoral artery tissue sections of the control group, mean tumor necrosis factor alpha and hypoxy-induced factor-1 alpha immunoreactivity were found to be negative. In the ischemia/reperfusion group, mean tumor necrosis factor α immunoreactivity was intense and mean hypoxy-induced factor-1 alpha immunoreactivity was 51–75%. In the ischemia/reperfusion + Sildenafil and ischemia/reperfusion + NAS groups, mean tumor necrosis factor α immunoreactivity was slight and mean hypoxy-induced factor-1 alpha immunoreactivity was 26–50%. Conclusions In conclusion, sildenafil and n-acetylcystein may reduce femoral artery endothelium and gastrocnemius muscle injury following lower extremity ischemia/reperfusion.

A rare etiology of heart failure: traumatic arteriovenous fistula due to stab injury 17 years ago

BACKGROUND Although traumatic fistula is frequently encountered, high-output heart failure due to fistula is a very rare condition. Despite an indefinitive history of trauma, arteriovenous (AV) fistula may develop insidiously, and therefore identification of a shunt is highly important for treatment. CASE REPORT Here we report a 46-year-old male patient with heart failure due to traumatic femoral arteriovenous fistula developed following a penetrating stab injury 17 years ago. CONCLUSION Traumatic AV fistula is a curable cause of heart failure. Also, careful examination of the patient is as significant as radiological imaging methods.

Aspirin versus clopidogrel for synthetic graft patency after peripheral arterial bypass grafting.

Usually, aspirin used as an antiplatelet agent is thought to be sufficient to ensure graft patency after surgical bypass procedures. However, clopidogrel can also be considered as an alternative to aspirin. – 4 We have performed a preliminary fact-finding study in an attempt to compare the efficacies of aspirin and clopidogrel on long-term synthetic graft patency following peripheral arterial revascularisation. Seventy-six peripheral arterial bypass operations were performed in 54 patients using polytetrafluoroethylene synthetic grafts. Twelve aortafemoral bypass, 45 above-knee femoro-popliteal bypass, three ilio-femoral bypass, seven aorta-bi-femoral bypass (two cases in this latter group were aorta-bi-femoral plus femoro-popliteal bypass) were performed. Eight-mm ringless grafts in the aorta-femoral location and 6-mm full ringed grafts in the above-knee femoro-popliteal location were preferred. Twenty-eight patients who had 39 bypass procedures each received 300 mg single daily dose acetylsalicylic acid (Aspirin®, Bayer) and 26 patients who had 37 bypass procedures each received 75 mg single daily dose clopidogrel (Plavix®, Sanofi). Arterial examination consisted of peripheral arterial pulses and monthly evaluation of synthetic grafts and peripheral arteries using Doppler ultrasound. Early graft occlusion occurred in two patients within 30 days of operation and these were excluded from the study. Details of the patients, follow-up times, patency rates and complications are summarised in Table 1. The aspirin group was followed up for a mean of 11±4.0 months and the clopidogrel group for a mean of 7.2±3.9 months. Graft patency rate was 81% in the aspirin group and 84% in the clopidogrel group. The mean time to graft occlusion was 8.4±4.6 months in the aspirin group and 5.5±1.7 months in the clopidogrel group. The difference was not statistically significant. There were less unpleasant side effects in the clopidogrel group compared to the aspirin group. Nausea, vomiting, diarrhoea, rash and bleeding were observed in the aspirin group. Diarrhoea in one case and nausea and vomiting in one case were observed in the clopidogrel group. Graft occlusions occur as a result of thrombosis of the graft due to an insufficient peripheral arterial system and constriction at the proximal or distal arteries due to progression of the systemic atherosclerosis. Another pathology is intimal and neo-intimal hyperplasia in the suture line. Antiplatelet drugs as aspirin are used for the prevention of anastomotic neointimal fibrous hyperplasia. The effects of clopidogrel on ischaemic events were evaluated in the multicenter CAPRIE study and it was suggested that clopidogrel is more effective and safer than aspirin. However, in our study no clear difference was found between the efficacy of aspirin and clopidogrel. Although times of follow-up were not equal,

Body mass index as a determinant of postoperative morbidity

BACkGRouND: The impact of obesity on postoperative mortality and morbidity in coronary artery bypass grafting (CABG) operations is a widely studied but poorly defined topic. oBjECTIVE: To investigate the effect of body mass index (BMI) on inhospital mortality and morbidity after isolated CABG surgery. METhoDS: Prospectively collected data of a series of 1057 consecutive patients who underwent on-pump isolated CABG surgery were retrospectively analyzed. Patients were divided into five groups according to WHO BMI categorization (defined as underweight [BMI <20 kg/m2]; normal weight [BMI ≥20 kg/m2 to <25 kg/m2]; overweight [BMI ≥25 kg/m2 to <30 kg/m2]; obese [BMI ≥30 kg/m2 to <35 kg/m2]; and morbidly obese [BMI ≥35 kg/m2]). RESulTS: Of 1057 patients, 13 patients (1.2%) were underweight, 298 (28.2%) were normal weight, 462 (43.7%) were overweight, 218 (20.6%) were obese and 66 (6.2%) were morbidly obese. The mean age was significantly lower in underweight patients, who were also more likely to be male. In contrast, obese and morbidly obese patients were older, and more likely to have comorbidities such as diabetes and hypertension. The incidence of postoperative bronchodilator use (P<0.001), leg wound infection (P=0.038), sternal dehiscence (P=0.039) and development of new-onset atrial fibrillation (P<0.001) was significantly higher in obese and morbidly obese groups. In contrast, postoperative prolonged ventilation (P<0.001), need for blood transfusions (P<0.001) and revision for bleeding (P=0.041), as well as gastrointestinal complications (P<0.001), were significantly higher in underweight patients. Multivariate logistic regression analysis showed that female sex, older age and diabetes mellitis, but not BMI, were independent risk factors for early mortality after CABG surgery. CoNCluSIoN: No effect of BMI on early postoperative mortality after CABG surgery could be demonstrated. However, in terms of morbidity, postoperative bleeding and revision for bleeding were increased in underweight patients while sternal dehiscence, wound infections and occurrence of atrial fibrillation were increased in obese and morbidly obese patients.