Tekin Yildirim

Clopidogrel-induced hypersensitivity syndrome associated with febrile pancytopenia

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Coronary artery bypass surgery in patients with severe left ventricular dysfunction

OBJECTIVE The role of coronary artery bypass grafting (CABG) in patients with severe left ventricular dysfunction was evaluated. METHODS Two hundred and twelve patients (152 men, 60 women; age 35 to 82, mean 55) with ejection fraction (EF) of less than 30% underwent CABG between January 1996 and February 2001 by a single surgeon (SA). They compromised of 12% of 1759 patients operated on in this period. EF ranged from 17% to 30% (mean 25%). Preoperatively 68% had congestive heart failure and 72% had severe angina (CCS 3 or 4). A left main lesion was found in 26% of the cases. The mean number of grafts was 3.18 per patient. The left internal mammary artery (LIMA) was used on 107 patients (50.4%). Preoperative intraaortic balloon pump (IABP) was used on 32 patients (15%). Endarterectomy was performed on 53 patients (25%). The patients were followed for up to 58 months (mean 28.7). RESULTS Twelve patients died in hospital (5.6%). Survival was 94%, 87%, 80% and 73% at 1, 2, 3 and 4 years respectively. Among the preoperative variables survival was negatively affected by chronic renal failure, older age, congestive heart failure, elevated pulmonary artery pressure and recent myocardial infarction, by means of multivariate analysis. Preoperative IABP support improved the operative mortality significantly (P=0.002). Use of LIMA did not have any influence on survival. CONCLUSION CABG on patients with poor left ventricular function: (1). Can be performed with an acceptable mortality. (2). Mid term results are encouraging. (3). Preoperative IABP support improves the chance of survival.

The quality of life after cardiac surgery in octogenarians and evaluation of its early and mid-term results.

OBJECTIVE The aim of this study is to evaluate our early and mid- term results and the qualities of life of the patients aged eighty years or older who underwent heart surgery. METHODS Eighty- eight patients aged 80 years and older who underwent open-heart surgery at Göztepe Şafak Hospital between May 2004 and December 2010 have been included to the study. This study was designed as two-stage: in the first stage, determinants of survival were analyzed retrospectively. In the second stage, the quality of life of survived patients was evaluated by using Short- Form 36 (SF-36), Turkish version in the cross-sectional study. The statistical analysis was performed using Fischers exact, Pearson Chi-square test, Student t-test, Mann-Whitney U test and logistic regression analysis. RESULTS In the logistic regression analysis; the left ventricular ejection fraction as <50% (OR: 11.02, 95% CI: 2.6-46.6, p<0.05), application of redo surgery (OR: 8.3, 95% CI: 1.04-66.6, p<0.05), coronary bypass and mitral surgery procedures in the same session (OR: 9.2, 95% CI: 1.6-53.7, p<0.05), left main coronary lesion as >50% (OR: 4.3, 95% CI: 1.1-17.7, p<0.05), preoperative creatinine as >1.8 mg/dl (OR: 14.1, 95% CI: 2.6-76.1, p<0.01), New York Heart Association class III-IV (OR: 4.9, 95% CI: 1.2-20.1, p<0.05), chronic obstructive pulmonary disease (OR: 10.3, 95% CI: 2.5-41.7, p<0.01) were found to be risk factors of hospital mortality. Physical functions, social functions and all sub-scales other than the role limitation depending on the emotional situation were evaluated as general population mean or above. CONCLUSION We think that with a successful heart surgery in patients aged 80 years and older under appropriate conditions, their life qualities and mean life expectations can return to normal and they can lead a symptomless life.

An Alternative Technique of Proximal Anastomosis in Patients with an Atherosclerotic Ascending Aorta

Coronary artery bypass grafting operations in patients with an atherosclerotic ascending aorta are still associated with an increased risk of cerebral embolism and mortality despite previously described techniques. Here we present an alternative technique for the construction of a proximal anastomosis avoiding aortic clamping and deep hypothermic circulatory arrest.

Simultaneous carotid endarterectomy and myocardial revascularization by using cardiopulmonary bypass for both procedures

Objective — The optimal treatment of patients with co-existing occlusive coronary and carotid arterial disease is controversial. This study reports our experience with simultaneous carotid endarterectomy and coronary bypass in conjunction with cardiopulmonary bypass with mild hypothermia. Methods and results — From March 2001 to June 2004, 72 patients underwent simultaneous coronary bypass and carotid endarterectomy.Their mean age was 68.9 years and there were 56 men and 16 women.The indication for carotid endarterectomy was a lumen diameter reduction of more than 75% and/or the presence of ulcerated/unstable plaque. Carotid endarterectomy was done during cardiopulmonary bypass under mild hypothermia, haemodilution, systemic heparinization and controlled haemodynamics under pulsatile perfusion for additional cerebral protection. The mean cardiopulmonary bypass time was 64.7 minutes and aortic cross-clamp time 32.4 minutes, and the mean number of grafts per patient was 2.7. Four patients had perioperative neurological complications (5.5%) and two had permanent deficits (2.7%).The procedure-related mortality was 3 (4.1%). Conclusions — We suggest that combining coronary revascularization and carotid endarterectomy and performing both under cardiopulmonary bypass is safe, offering acceptable morbidity and mortality rates.

Does the surgical technique used in the orthotopic heart transplant affect the results regarding the rhythm

OBJECTIVE The aim of this study was to compare the requirement for temporary and permanent pacemaker insertion and the incidence of the problems regarding the rhythm following heart transplantation with the bicaval or biatrial technique in the early postoperative period. METHODS Sixty-one patients underwent orthotopic heart transplantation between the dates of September 1989 and December 2008 in our clinics were included to the study. The study was designed as retrospective analysis, and all data were collected from hospital records. The transplantation was performed by using standard biatrial method in 28 of the patients, by using bicaval anastomosis method in 33 of the patients. Statistical analyses were performed using Chi-square, Fischers exact and Mann-Whitney U tests. Predictors of temporary and permanent pacemaker insertion were analyzed using logistic regression analysis. RESULTS In the biatrial group, the temporary pacemaker requirement (p<0.05), left bundle branch block (LBBB) (p<0.01) and atrioventricular block (AV block) (p<0.05) were observed statistically significantly more than in bicaval anastomosis group. In addition, in the biatrial group, one patient needed implantation of permanent pacemaker and one patient-implantable cardioverter defibrillator. On the postoperative echocardiographic evaluation, in the patients operated with the bicaval technique, the tricuspid (p<0.01) and mitral insufficiency (p<0.01) were observed significantly less. In the logistic regression analysis, hypertension (OR: 1.053, 95% CI: 1.019-1.176, p<0.05), donor age (OR: 1.016, 95% CI: 1.023-1.038, p<0.05) and application of the operation with the biatrial technique (OR: 10.287, 95% CI: 1.298-91.278, p<0.01) were determined as the risk factors requiring the temporary pacemaker usage. In the bicaval group, arrhythmia (ventricular and atrial premature beats) and atrioventricular valve insufficiency were observed less, the rhythm returned to normal in an earlier period. CONCLUSION Biatrial surgical technique, donor age and hypertension were determined as significant predictors of temporary pacemaker insertion in the orthotopic heart transplantation. Atrioventricular block, left bundle branch block, and arrhythmia frequency was significantly less in the bicaval group. In terms of factors affecting morbidity, the bicaval technical results were found superior than biatrial technique.

Results of Adjunctive Coronary Endarterectomy in 548 Patients

Coronary endarterectomy is a controversial procedure that plays a particular role in the treatment of coronary artery disease. We retrospectively investigated the results for 548 patients who underwent coronary endarterectomy as an adjunctive therapy for coronary artery bypass graft surgery during the period between 1996 and 2004. We assessed short-term outcomes and identified risk factors for adverse outcomes. Mean patient age was 67.9 + 9.3 years and mean angina class was 2.7 + 0.3. The mean number of distal anastomoses was 3.8 + 1.1 patients (73.4%) had single and 151 (27.6%) multiple coronary artery endarterectomies. Of the 151 patients who underwent multiple endarterectomies, 97 (17.7%) had endarterectomies in 2 coronary arteries, 40 (7.2%) in 3 coronary arteries, 11 (2%) in 4 coronary arteries, 2 (0.36%) in 5 coronary arteries, and 1 (0.18%) in 6 coronary arteries. Postoperative mortality was 6.2% (34 patients). The predictors for early mortality were recent myocardial infarction and left ventricular dysfunction. Our results suggest that adjunctive coronary endarterectomy can be accomplished with acceptable results but with higher mortality rates than ordinary coronary artery bypass grafting. Adjunctive coronary endarterectomy should be considered as a last option for the surgical treatment of diffuse coronary disease.

Reperfusion Strategy after Regional Ischaemia: Simulation of Emergency Revascularization and Effects of Integrated Cardioplegia on Myocardial Resuscitation

We induced ischaemia in the left anterior descending artery of 16 dogs while the heart was beating, followed by cardiopulmonary bypass (CPB), aortic cross clamping and blood cardioplegia. Half of the dogs received integrated blood cardioplegia and sudden uncontrolled reperfusion (group A) while the others received the same cardioplegia followed by pressure-controlled tepid initial reperfusion (group B). The effects on myocardial cell metabolism, oxidative stress and ultrastructure were recorded. The recovery period was significantly longer and cardiac output levels after CPB significantly lower in group A compared with group B. Group A showed a failure to uptake and utilize oxygen during the recovery period and significant lipid peroxidation. Marked tissue oedema was seen in group A but mitochondrial and organelle integrity was almost normal in both groups. We conclude that integrated cardioplegia could partially resuscitate the myocardium in this model, and pressure controlled reperfusion during the first 2 min is needed as an adjunct procedure.

Simultaneous coronary artery bypass grafting and ascending aorta to bifemoral bypass for ischemic heart disease combined with critical leg ischemia: case reports.

Coronary artery disease may coexist with aortoiliac occlusive disease, and concomitant revascularization procedures may be required. The ascending aorta may be used as the source of inflow to both the femoral and coronary arteries in patients who present with coronary artery disease and critical leg ischemia. We present here 2 patients in whom coronary artery bypass grafting and ascending aorta-to-bifemoral bypass operations were performed simultaneously.