Ugursay Kiziltepe

Effects of Combined Conventional and Modified Ultrafiltration in Adult Patients

BACKGROUND Modified ultrafiltration (MUF) improves hemodynamics and postoperative recovery in children. Ultrafiltration (UF) may have similar benefits in adults. The purpose of this study was to investigate the effects of UF in adult patients. METHODS A total of 40 adult patients undergoing cardiac surgery were randomized into a study group of conventional UF during bypass + venovenous MUF after bypass and a control group with no UF. Perioperative clinical variables, cytokines, and endothelin-1 levels were compared between groups. RESULTS There was no mortality in either group. The patients in the study group had a greater rise in hematocrit (5.7% +/- 2.4% vs 1.2% +/- 1.9%, p < 0.001), hemoglobin (1.7 +/- 0.8 mg/mL vs 0.5 +/- 0.6 mg/mL, p < 0.0005), and platelet levels (27,800 +/- 29,200 vs -9,000 +/- 30,970, p < 0.001). Mean arterial blood pressure and CI increased after MUF (from 64.2 +/- 16.9 mm Hg to 72.3 +/- 14.1 mm Hg, p = 0.05, and from 2.4 +/- 0.7 to 2.8 +/- 0.6, p < 0.03, respectively). Postoperative oxygenation was better in the study group (alveolo-arterial PO2 tension gradient 74.6 +/- 43.9 mm Hg vs 107.2 +/- 27.8 mm Hg, p = 0.03). Ultrafiltration reduced postoperative bleeding (522.2 +/- 233.4 mL vs 740 +/- 198.4 mL, p < 0.003). CONCLUSIONS A combination of conventional and modified UF is effective and safe in adult patients undergoing cardiac surgery. Ultrafiltration improved hemodynamics, hemostatic, and pulmonary functions. We recommend the use of combined UF in high-risk adult patients.

Long-term results of reconstructions of the left anterior descending coronary artery in diffuse atherosclerotic lesions

UNLABELLED One hundred twenty patients who had diffuse atherosclerotic lesions necessitating reconstruction of the left anterior descending artery with or without open endarterectomy and coronary artery bypass grafting were investigated retrospectively and compared with 130 patients who underwent conventional bypass grafting in the same time frame. METHODS Sixty-one endarterectomies were performed with long arteriotomies (group I) and 59 patch reconstructions were placed over stenosing plaques without an endarterectomy (group II). Patients having only conventional coronary bypass constituted group III. RESULTS Hospital mortalities were 6.5%, 5.1%, and 1.5% in group I, group II, and group III, respectively (p = not significant). Five patients in group I (8.1%), six in group II (10.1%), and two in group III (1.5%) had perioperative myocardial infarction (group II vs group III, p = 0.016). Angiographic restudy of grafts to the left anterior descending system revealed a patency rate of 81.5% in group I, 79.1% in group II, and 94.4% in group III patients after mean periods of 6.3, 5.7, and 6.1 years, respectively (p = not significant). Actuarial survivals at 7 years were 94% +/- 5.0%, 74.8% +/- 16%, and 90.9% +/- 7.4% in groups I, II, and III, respectively (group I vs group II, p = 0.007; group II vs group III, p = 0.008). Freedom from recurrent angina at 7 years was 42.7% +/- 15.6% in group I, 33.5% +/- 19% in group II, and 71.9% +/- 14.2% in group III (group I vs group III, p = 0.03; group II vs group III, p = 0.0001). Thirty-four percent of patients in group I, 24% in group II, and 60.4% in group III were working actively in the late postoperative period (p = 0.0001). CONCLUSION Extended revascularizations of the left anterior descending coronary artery increase surgical risk, although not to a statistically significant degree, and should be performed only of necessity. However, once needed, revascularization is a lifesaving procedure with acceptable early and long-term results.

Comparative study of microfibrillar collagen hemostat (Colgel) and oxidized cellulose (Surgicel) in high transfusion-risk cardiac surgery

OBJECTIVE The effects of microfibrillar collagen hemostat (Colgel) and oxidized cellulose (Surgicel) on bleeding and allogeneic transfusions were compared in cardiac operations with a predicted high risk of bleeding. METHODS Between August 1999 and November 2001, 71 patients undergoing elective, high risk of bleeding operations were studied after giving informed consent. The procedures included repeat cardiac operations (aorta-coronary bypass operations or valvular operations), ascending aortic aneurysm repair necessitating deep hypothermic circulatory arrest, and ascending aortic grafting without deep hypothermic circulatory arrest. Subjects were excluded if they had recent (<5 days) acetylsalicylic acid ingestion, thrombolytic therapy, or anticoagulant therapy (heparin <4 hours preoperatively or warfarin <3 days preoperatively). Consenting subjects were randomized to receive either Colgel or Surgicel. RESULTS Chest tube drainage in the first 24 hours was 373 +/- 143 mL in the Colgel group and 571 +/- 144 mL in the Surgicel group (P =.01). Total postoperative chest tube drainage was 423 +/- 154 mL (range, 280-1100 mL) in the Colgel group and 677 +/- 128 mL (range, 285-1350 mL) in the Surgicel group (P =.01). In addition, chest tube drainage was compared between the 2 groups every 3 hours after operation. Blood loss in the first 3 postoperative hours was significantly less in the Colgel group (132 +/- 41 vs 228 +/- 57 mL, P <.001). In the following 3-hour interval, this significant difference persisted (67 +/- 24 vs 121 +/- 49 mL, P <.001). CONCLUSIONS In conclusion, the easy application, low cost, and significant blood-loss reduction effect of microfibrillar collagen powder renders this agent attractive for cardiac operations associated with high risk of bleeding.

Antiarrhythmic effect of magnesium sulfate after open heart surgery: effect of blood levels

BACKGROUND Arrhythmias following cardiac surgery is still a difficult complication to treat. Magnesium sulfate is an effective antiarrhythmic agent with negligible side effects. In this study, effects of magnesium sulfate as a first line antiarrhythmic agent was compared with results of two different well-accepted antiarrhythmic agents. METHODS One hundred patients with arrhythmia were prospectively randomized to a study and a control group. Lidocaine and amiodarone were accepted as standard antiarrhythmic agents. Patients in study group were received magnesium sulfate routinely as a first line antiarrhythmic agent. Unresponsive arrhythmias were treated with standard antiarrhythmic agents. Control group patients received only standard antiarrhythmics. RESULTS Magnesium sulfate alone was effective in 56% of the study group whereas 74% of the control group were responsive to standard antiarrhythmics (P=n.s.). In study group, a subgroup analysis according to blood levels of Mg2+ revealed that magnesium sulfate was more effective in patients with low Mg2+ levels (63% for low Mg2+ levels, 55% for normal Mg2+ levels, 36% for high Mg2+ levels) and ventricular arrhythmias (60% for ventricular and 40% for supraventricular arrhythmias), without statistical significance. CONCLUSIONS Magnesium sulfate is an effective and safe antiarrhythmic agent for arrhythmias developed after open-heart surgery. Its antiarrhythmic effect may relate to its pharmacological properties and unrelated to normalization of the circulating magnesium concentrations. We recommend its use as a first line antiarrhythmic agent without routine measurement of blood levels.

Conduction disturbances in coronary artery bypass surgery.

BACKGROUND Conduction disturbances are very common after coronary artery bypass grafting (18-45%). Long cross-clamp time, method of cardioplegia, depth of hypothermia, and patient age are some of the risk factors. We planned this study to ascertain the effect of crystalloid or tepid blood cardioplegia (CP) on conduction disturbances. METHODS One hundred patients were randomly divided into two groups. The first group received tepid blood CP and the second received cold crystalloid CP. St. Thomas II CP was used as CCP and the same CP was mixed with blood with a ratio of 4:1 in the tepid CP group. In both groups as an initial bolus, a 10 to 15 ml/kg CP was infused with a pressure of 75 mmHg. Additionally, 400 ml of CP were given every 20 min during the cross clamping period in addition to infusion of 50-100 ml of CP after each distal anastomosis. Blood samples for CK, CK-MB, LDH and Troponin T measurements were obtained at induction, before bypass, after cross clamping, before de-clamping, after de-clamping and after bypass. Postoperative ECGs were analyzed by a cardiologist. RESULTS There were no deaths in both groups but the mean hospitalization was 8.4 +/- 1.7 days in group I, and 14.4 +/- 3.1 days in group II (P=0.004). Although there were significant rises in CK, CK-MB, LDH and Troponin T levels in both groups after CPB or de-clamping, the difference in increment between the two groups was not significant. Twelve patients in group II (24%) developed new fascicular blocks, four of these caused hemodynamic instability and needed inotropic treatment but only one was discharged with LAHB. Four patients in group I (8%) also developed new conduction disturbances within the first hour, but all completely resolved. Incidence of conduction disturbances was significantly increased in the crystalloid CP group (P=0.019). CONCLUSION There were no significant differences in cardiac enzyme measurements between cold crystalloid and tepid blood CP, but crystalloid CP caused more fascicular blocks. We conclude that myocardial protection was equal in both cardioplegia methods whereas conduction disturbances have been assumed to be caused by cold injury to the conduction tissues.

Prolonged pleural effusion following Fontan operation: effective pleurodesis with talc slurry

Prolonged pleural effusions following a Fontan operation are a difficult problem. Although fenestrations and embolizations of systemic-pulmonary artery collaterals were suggested to treat and to decrease the risk of this complication, talc slurry pleurodesis may successfully augment and accelerate the beneficial effects of those techniques against the resistant effusions.

The changing aetiological spectrum of pericarditis in children

Abstract The aetiologies, clinical features and follow-up data of 62 children with pericarditis admitted to a university hospital during a 6-year period were retrospectively assessed. Uraemic pericarditis was the most frequent and infections the second most frequent cause. In this series, the proportion of children with purulent pericarditis is less than in previous reports from developing countries. Familial Mediterranean fever, neoplasias, acute rheumatic fever and post-pericardiotomy syndrome were other important causes of pericarditis.

Acute pulmonary hypertensive crisis after TAPVC repair treated with atrial septectomy with inflow occlusion

Acute pulmonary hypertensive crisis is a fatal complication after obstructive TAPVC repair. An atrial septectomy or enlargement of a small ASD could be a lifesaving procedure in order to maintain cardiac output in severe cases. This procedure can be accomplished with inflow occlusion in patients with critical condition.

Left sided inferior vena cava with sinus venosus type atrial septal defect

A patient with left sided inferior vena cava and sinus venosus type atrial septal defect is presented. The patient was situs solitus, had abnormal pulmonary venous drainage and the left sided inferior caval vein returned to its usual route after the renal vein junction.

Comparison of heat induced damage at the saphenofemoral junction after ablation with 1,470 nm laser or radiofrequency

BACKGROUND The aim of this study was to evaluate the heat induced damage at the saphenofemoral junction level according to histopathological changes after radiofrequency or 1,470 nm radial tip laser ablation. PATIENTS AND METHODS Varicose vein segments of 6-10 mm in diameter were exposed to radiofrequency (Closure Fast catheter, 7 cm heat segment, one cycle, 15 seconds, 10 Watt, 120 °C) or laser ablation (1,470 nm radial tip, continuous wave, vein diameter: 6 cm/8 cm/10 cm-power: 10 Watt-pullback speed: 2.2 mm/s, 1.7 mm/s, 1.3 mm/s-LEED: 45J/cm, 60J/cm, 75J/cm-EFE 25J/cm2, respectively). Approximate 2 cm segments of the vein were left untreated, then histopathological examinations of the untouched segments (5 slices: level 1 - furthest segment, level 2 - nearest segment) for heat induced damage were performed. A total damage scoring system was established, including the presence of endothelial swelling, intimal thickening, cellular vacuolisation in the muscle layer, oedema in the tunica media, and extent of necrosis. RESULTS At level 1, the furthest segment of the specimen, there was no significant difference between the laser and control group, while the total damage score of the radiofrequency group was significantly higher than the control group (p < 0.01). Radiofrequency group had higher total damage score compared to the laser group at level 1 (p < 0.01), 2 (p < 0.01), and 5 (p < 0.01); while no significant difference was observed at level 3 (p = 0.46) and 4 (p = 0.13). CONCLUSIONS Significant heat induced damage may be seen even if the 2 cm segment of the vessel is left unablated. Radiofrequency ablation seems to cause more histological damage than laser ablation in this ex vivo study. Further in vivo studies are necessary, in order to validate these findings.