Tanzer Calkavur

Prophylactic dialysis in patients with renal dysfunction undergoing on-pump coronary artery bypass surgery

BACKGROUND Preoperative creatinine values higher than 2.5 mg/dL are associated with markedly increased risk for both mortality and morbidity in patients undergoing coronary artery bypass surgery. We aimed to determine the effects of prophylactic perioperative hemodialysis on operative outcome in patients with nondialysis-dependent moderate renal dysfunction. METHODS Forty-four adult patients with creatinine levels greater than 2.5 mg/dL but not requiring dialysis underwent coronary artery bypass surgery with cardiopulmonary bypass. The patients were randomly divided into two groups. In group 1 (dialysis group, 21 patients), perioperative prophylactic hemodialysis was performed in all patients. Group 2 (23 patients) was taken as a control group and hemodialysis was performed only if postoperative acute renal failure was diagnosed. RESULTS The hospital mortality was 4.8% (1 patient) in the dialysis group, and 30.4% (7 patients) in the control group (p = 0.048). Postoperative acute renal failure requiring hemodialysis was seen in 1 patient (4.8%) in the dialysis group and in 8 patients (34.8%) in the control group (p = 0.023). Thirty-three postoperative complications were observed in the control group for an early morbidity of 52.2% (12 patients) and 13 complications occurred in 8 patients in the dialysis group (38.1%). The average length of the intensive care unit and postoperative hospital stay were shorter in the dialysis group than in the control group (p = 0.005 and p = 0.023, respectively). CONCLUSIONS Preoperative creatinine levels higher than 2.5 mg/dL, increase the risk of mortality and the development of acute renal failure and prolong the length of hospital stay after on-pump coronary artery bypass surgery. Perioperative prophylactic hemodialysis decreases both operative mortality and morbidity in these high-risk patients.

Amiodarone reduces the incidence of atrial fibrillation after coronary artery bypass grafting

OBJECTIVE The purpose of this study was to evaluate the safety and efficacy of postoperative administration of prophylactic amiodarone in the prevention of new-onset postoperative atrial fibrillation in patients undergoing coronary artery bypass grafting. METHODS In this prospective study 157 patients were randomly divided into two groups: 77 patients (amiodarone group) received intravenous amiodarone in a dose of 10 mg/kg/d for postoperative 48 hours. On postoperative day 2 oral amiodarone was started with a dose of 600 mg/d for 5 days, 400 mg/d for the following 5 days, and 200 mg/d for 20 days, and 80 patients received placebo (control group). RESULTS Preoperative patient characteristics and operative variables were similar in the two groups. Postoperative atrial fibrillation occurred in 8 patients (10.4%) receiving amiodarone and in 20 (25.0%) patients receiving placebo (P =.017). Duration of atrial fibrillation was 12.8 +/- 4.8 hours for the amiodarone group compared with 34.7 +/- 28.7 hours for the control group (P =.003). The maximum ventricular rate during atrial fibrillation was slower in the amiodarone group than in the control group (105.9 +/- 19.1 beats per minute and 126.0 +/- 18.5 beats per minute, respectively, P =.016). The two groups had a similar incidence of complication other than rhythm disturbances (20.8% vs 20.0%, P =.904). Amiodarone group patients had shorter hospital stays than that of control group patients (6.8 +/- 1.7 days vs 7.8 +/- 2.9 days, P =.014). The in-hospital mortality was not different between two groups (1.3% vs 3.8, P =.620). CONCLUSIONS Postoperative intravenous amiodarone, followed by oral amiodarone, appears to be effective in the prevention of new-onset postoperative atrial fibrillation. It also reduces ventricular rate and duration of atrial fibrillation after coronary artery bypass grafting. It is well tolerated and decreases the length of hospital stay.

Perioperative Risk Factors for Mortality in Patients With Acute Type A Aortic Dissection

BACKGROUND This study was undertaken to identify the perioperative risk factors for death in patients with acute type A aortic dissection (AADA). METHODS Between 1993 and 2001, 108 consecutive patients (86 men; mean age, 53 years) underwent emergent operations for AADA. All patients but 2 underwent replacement of the ascending aorta with an open distal anastomosis during a period of hypothermic circulatory arrest. In addition, 22 patients had hemiarch and 5 had total arch replacement. Aortic root was replaced in 20 and repaired with gelatin-resorcinol-formaldehyde glue in 39 patients; aortic valve was separately replaced in 3, resuspended in 24, and remained untouched in 22 patients. RESULTS Overall in-hospital mortality was 25%. Mortality rate was significantly higher in patients with preoperative dissection complications than in those without (21/36 [58%] vs 6/72 [8%], p < 0.001). In multivariate analysis, predictors of mortality were presence of rupture, renal failure, and intestinal malperfusion, duration of cardiopulmonary bypass > or = 200 minutes, blood loss > or = 500 mL, and transfusion of blood > or = 4 units. Location of the intimal tear, extent of the replacement, type of the aortic root repair, and duration of hypothermic circulatory arrest did not emerge as predictors of mortality. CONCLUSIONS Major determinants of surgical mortality in patients with AADA are preoperative complications. Earlier diagnosis remains essential to improve the survival rate.

Perigraft to right atrial shunt by using autologous pericardium for control of bleeding in acute type A dissections

BACKGROUND We report our experience with creating a perigraft to right atrial fistula by using autologous pericardium to control the inaccessible bleeding after aortic root repair in patients with acute type A aortic dissection. METHODS Between 1994 and 2001, perigraft to right atrial fistula was used in 7 of 109 patients (mean age; 55 years) who underwent emergency operation for acute type A dissections. A chamber around the aortic graft was created by suturing a patch of pericardium to the right ventricular wall inferiorly, to the pulmonary artery medially, to the Teflon felt at the distal aortic anastomosis or innominate vein superiorly, and to the superior vena cava and right atrium laterally. A large stab wound was created on the medial aspect of the right atrium. The perigraft space was then closed expeditiously. RESULTS None of these patients required reexploration for bleeding and they were discharged from the hospital without complications. The average blood and fresh frozen plasma requirement was 3.4 +/- 0.9 and 2.7 +/- 0.7, respectively. All underwent echocardiographic examination before discharge and no perigraft to right atrial shunt was detected. CONCLUSIONS If intractable bleeding is encountered after the administration of protamine and thrombotic agents and a discrete bleeding site can not be found, then a perigraft to right atrial fistula using autologous pericardium can be created as a last resort. It provides primary and definite sternal closure and avoids the detrimental effects of a second pump run and continued bleeding.

Right intra-atrial catheter placement for hemodialysis in patients with multiple venous failure

The purpose of this study is to evaluate the efficacy and safety of direct right atrial catheter insertion for hemodialysis in patients with multiple venous access failure. We retrospectively evaluated the charts of 27 patients with multiple venous access failure who had intra‐atrial dialysis catheter placement between October 2005 and October 2010 in our clinic. Permanent right atrial dialysis catheters were placed through a right anterior mini‐thoracotomy under intratracheal general anesthesia in all patients. Demographics of the cases, the patency rates of hemodialysis via atrial catheterization, existence of any catheter thrombosis, and catheter‐related infections were documented and used in statistical analysis. Seventeen women (63%) and 10 men (37%) with the mean age of 59.0 ± 7.1 years (47–71) were enrolled in this study. Chronic renal failure was diagnosed for the mean of 78.9 ± 24.3 months (33–130). Five patients (18.5%) died. Ventricular fibrillation and myocardial infarction were the causes of death in the early postoperative period in two patients. Two of the remaining three patients died because of cerebrovascular events, and one patient died because of an unknown cause. Ten patients (37%) had been using anticoagulate agents (warfarin) because of concomitant disorders such as deep vein thrombosis, operated valve disease, and arrhythmias. Catheter thrombosis and malfunction was determined in three cases (11.1%). Intra‐atrial hemodialysis catheterization is a safe and effective life‐saving measure for the patients with multiple venous failure and without any possibility of peritoneal dialysis or renal transplantation.

Surgical Treatment of Acute Arch Dissection

OBJECTIVES Acute type A arch dissections are rare and no consensus has been reached on their surgical treatment. We studied perioperative risk factors for mortality in arch dissection patients. METHODS Between October 1995 and October 2001, 108 patients with acute type A dissection were operated on, of whom 16 had acute arch dissections. Their mean age was 58 +/- 9 (44-77). Surgery involved total arch replacement in 4, hemiarch replacement in 10, and intimal tear repair with pledgeted sutures and ascending aortic replacement in 2. RESULTS One patient who underwent total arch replacement died intraoperatively due to bleeding. Both patients who underwent ascending aortic replacement and primary repair of arch tears died 2 days postoperatively, 1 due to bleeding, and the other due to multiorgan failure. In-hospital mortality was thus 18.75%, or 3 of 16. All 3 had cardiac tamponade preoperatively. The 13 survivors were discharged after a mean hospital stay of 11 +/- 6 days. Mean follow-up was 38 +/- 25 months, from 3 months to 6 years. One patient died due to graft infection 3 months postoperatively, but the remaining 12 remain in good condition. Univariate predictors of in-hospital mortality were the type of surgery (primary intimal tear repair) (p = 0.027) and preoperative cardiac tamponade (p = 0.007). CONCLUSION Surgical treatment of acute type A-arch dissections can be done with reasonable mortality and mid-term survival comparable with those of other subgroups with acute type A dissection. As with series of arch dissections, our patient population is too small to draw specific conclusions, but our experience leads us to conclude that the sites of intimal tears should be resected in acute type A arch dissection.

CLINICAL RESULTS OF RETROGRADE CEREBRAL PERFUSION IN TREATMENT OF AORTIC DISEASE

Between 1993 and 1998, 106 adults underwent ascending aorta or aortic arch operations using deep-hypothermic circulatory arrest and retrograde cerebral perfusion via the superior vena cava. Aortic lesions were acute type I dissection in 44 (41.5%), chronic type I dissection in 12 (11.3%), acute type II dissection in 6 (5.7%), chronic type II dissection in 9 (8.5%), ascending aorta or aortic arch aneurysms in 34 (32.1%), and an aneurysm of the sinus of Valsalva with aortic arch aneurysm in 1 (0.9%). The overall neurologic dysfunction rate was 6.6%. Early mortality was 18.8%. By multivariate analysis, circulatory arrest longer than 60 minutes and chronic renal failure were significant predictors of neurological dysfunction. Female gender, preoperative hemodynamic instability, circulatory arrest longer than 60 minutes, preoperative neurological dysfunction, and preoperative organ malperfusion were significant predictors of early mortality. We concluded that retrograde cerebral perfusion minimized neurological complications by preventing debris and air emboli and by providing adequate metabolic support in patients who needed circulatory arrest for surgical treatment of aortic pathology.

Reoperative Off-Pump Right Subclavian Artery to Right Coronary Artery Bypass Grafting Without Full Sternotomy

Abstract  Stenosis or occlusion of a large right coronary artery or its vein grafts in symptomatic patients who underwent previous bypass grafting procedure with patent left‐sided grafts is mostly managed by percutaneous interventions. When percutaneous interventions fail, it is a difficult decision to reoperate on a such patient for a single‐vessel disease considering the risk of resternotomy. We present our technique which involves small anterior thoracotomy and partial sternotomy. (J Card Surg 2011;26:148‐150)

Predictive values of risk factors in carotid duplex scanning before peripheral vascular surgery

The objective of this study was to determine the predictive values of multiple atherosclerotic risk factors in using routine carotid duplex scanning for patients with peripheral vascular disease, even in the absence of any sign of carotid disease. From 1998 through 2000, 108 patients admitted for peripheral vascular reconstruction to our institution were preoperatively screened for carotid artery stenosis. Patients were examined for neurologic status and cervical bruits. As atherosclerotic risk factors, hyperlipidemia, diabetes, smoking, sex and age, coronary artery disease (CAD), coronary artery bypass surgery (CABG), and previous vascular operation were recorded, preoperative ankle-brachial pressure indexes (ABI) were calculated. All patients underwent routine carotid color duplex examinations preoperatively. Eighty five patients (78.7%) had mild (<50%) or no carotid artery stenosis, and 23 patients (21.3%) had significant (≥50%) carotid artery stenosis. Age (≥60 years), coronary artery disease, and carotid bruit were individual factors, and the combination of age ≥55 and hyperlipidemia had a significant value in predicting presence of ≥50% stenosis of one or both carotid arteries by univariate analysis. By multivariate logistic regression analysis, however, only carotid bruit was associated with carotid artery stenosis of ≥50% (p<0.001). Screening for asymptomatic carotid artery stenosis is indicated in patients with only carotid artery bruit and might be indicated in elderly patients with peripheral vascular disease. Routine screening or carotid artery stenosis in all patients is not an effective strategy.

Simple and Cost-Effective Gas Jet for Non-Pump Coronary Bypass Surgery

A gas jet is one method of achieving a bloodless surgical field. We describe a simple and cost-effective oxygen blower system for coronary artery bypass surgery performed without cardiopulmonary bypass.