Unsal Ersoy

Atrial fibrillation after coronary artery bypass surgery: predictors and the role of MgSO4 replacement.

Abstract Background: Supraventricular arrhythmias continue to complicate the postoperative course of patients undergoing myocardial revascularization. The aim of the study was to identify factors associated with atrial fibrillation (AF) and to determine the efficacy of postoperative magnesium sulphate (MgSO4) replacement on the incidence of AF after coronary artery bypass grafting (CABG) operation. Methods: Fifty patients undergoing CABG were studied prespectively. Consenting patients with good left ventricular function and without any documented arrhythmias were randomly divided into two groups of 25 patients each in a double‐blind fashion. The clinical characteristics of both groups were similar. In the study group, 200 mEq MgSO4 was given for the first 5 postoperative days, in the control group, placebo was given instead of MgSO4. Results: Five (20%) patients in the control group and one (4%) patient in the MgSO4 group experienced AF. There was no significant relationship between the development of AF and the following variables: age; sex; diabetes mellitus; hypertension; previous myocardial infarction; smoking; extension of coronary artery disease; aortic cross‐clamp time; number of grafts; cardiopulmonary bypass time; postoperative pericarditis; and anemia. Conclusion: The use of MgSO4 in early postoperative period is effective in reducing the incidence of AF after CABG in patients with good ventricular function.

The changes and effects of the plasma levels of tumor necrosis factor after coronary artery bypass surgery with cardiopulmonary bypass.

BACKGROUND Systemic inflammatory response after cardiopulmonary bypass (CPB) is thought to result from contact of cellular and humoral blood components with the synthetic material of the extracorporeal circulation system, leukocyte and endothelial activation caused by ischemia and reperfusion or endotoxins, or by surgical trauma. Proinflammatory cytokines, such as tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, and IL-8, play an important role in the inflammatory processes after CPB and may induce cardiac and lung dysfunction. This study examined the association of the increased release of TNF-alpha with increased myocardial and lung injury after CPB and its effect on postoperative morbidity. METHODS Twenty patients undergoing elective coronary artery bypass grafting (CABG) were included in the study. Four intervals of blood samples were obtaind and assayed for TNF-alpha, white blood cells, C-reactive protein, and erythrocyte sedimentation rate. RESULTS All patients were similar with regards to preoperative and intraoperative characteristics, and clinical outcomes were comparable. Plasma levels of TNF-alpha rose more than 20 pg/mL during and after standard CPB in 13 patients (group 1), whereas the plasma levels were less than 20 pg/mL in the remaining 7 patients (group 2) after CPB. The patients of the first group had increased mediastinal bleeding and prolonged intubation time compared to the other group. CONCLUSION Cardiac surgery and CPB stimulate systemic inflammatory processes characterized clinically by changes in cardiovascular and pulmonary function. Significant morbidity is rare, but most patients undergoing CPB exhibit some degree of organ dysfunction due to activation of the inflammatory response. This study showed that there were no major clinical results of TNF-alpha and white blood cell level, C-reactive protein, and erythrocyte sedimentation rate after the operation, but in patients with a high level of TNF-alpha (more than 20 pg/mL), increased mediastinal bleeding and longer orotracheal intubation time was observed. A number of studies have shown the increase of TNF-alpha after open heart surgery; however, the specific level of TNF-alpha was first described as 20 pg/mL in this study.

Demonstration of Coronary Arteries and Major Cardiac Vascular Structures in Congenital Heart Disease by Cardiac Multidetector Computed Tomography Angiography

BACKGROUND Detection of coronary artery is important when considering surgical treatment of a congenital heart disease (CHD) such as tetralogy of Fallot (TF). Cardiac catheterization plays an important supplementary role in the evaluation of patients with CHD. In a few reports, it has been proposed that multidetector computed tomography (MDCT) can be helpful for the visualization of coronary arteries. We sought to demonstrate the feasibility and usefulness of MDCT angiography for anatomical evaluation of coronary arteries in CHD patients with suspected coronary artery anomalies. MATERIALS AND METHODS A total of 10 patients, 9 pediatric and 1 adult, underwent MDCT angiography for the investigation of coronary artery anomalies and mediastinal vascular structures. Seven patients had TF; 5 of these patients were suspected of having coronary artery anomalies and 2 were suspected of having pulmonary artery atresia or a nonconfluent pulmonary artery. The other 3 patients had truncus arteriosus and severe left pulmonary artery stenosis (n = 1), double outlet right ventricle (n = 1), and Kawasaki disease (n = 1) with suspected coronary artery aneurysms. The entire heart, major vascular structures, and coronary artery anomalies were preoperatively scanned in patients with cyanotic heart disease. Examinations were performed by 16-MDCT with 1-mm slice thickness. A breath-holding test was performed in 5 patients. Nonionic iodinated contrast material (2 cc/kg) was administered by a power injector. RESULTS Major vascular structures and the proximal part of the right and left coronary arteries were visualized successfully in all patients. Mid and/or distal segments of the coronary arteries were visualized in 5 patients with TF. Pulmonary vascular bed findings were also confirmed during surgery in patients with TF and in one patient with truncus arteriosus type I and severe left pulmonary artery stenosis. Kawasaki disease was diagnosed by the presence of aneurysms in one patient. Pulmonary artery atresia was confirmed in one patient and diameter of the pulmonary arteries (4 mm and 4.5 mm) was determined in the other 2 patients by MDCT. CONCLUSION The advantage of MDCT for cardiac imaging is the shortened scanning time for imaging the entire heart without long breath-holding times. Selective conventional coronary angiography is invasive and technically difficult in pediatric patients. We suggest that MDCT angiography can be performed as a noninvasive method in patients with CHD for the evaluation of coronary artery anatomy and anomalies and mediastinal vascular structures.

Brachial plexus neuroma mimicking local recurrence of malignant mesenchymal tumor after forequarter amputation.

A stump neuroma is an attempt for the repair of a nerve following amputation. This article presents a case of a 60-year-old woman who was suspected of having a local recurrence on the chest wall following amputation of the left arm for a malignant mesenchymal tumor. The tumor did not show any invasion to adjacent structures thereby any necessity for chest wall resection and reconstruction. The patient underwent local excision of the tumor with reamputation of the branches of the lower brachial plexus, subclavian artery, and proximal one third of the clavicle. The tumor was eventually diagnosed as a brachial plexus neuroma. Although rare, cases that require left pneumonectomy with a transthoracic forequarter amputation including brachial plexus resection have been reported. Transection of the brachial plexus also may be needed during resection of a superior sulcus tumor. These cases often undergo an aggressive chest wall resection that includes the subclavian artery and vein in addition to the brachial plexus, particularly in tumors involving the lower truncus. Therefore, when recurrent chest wall tumor is suspected in such cases, stump neuroma resulting from transection of the brachial plexus should be included in the differential diagnosis.

Diagnosis of perigraft seroma by use of different techniques in infants with respiratory distress after modified Blalock-Taussig shunt.

commonly used material in modified Blalock–Taussig shunts in infants. Perigraft seroma is a collection of a nonsecretory fibrous pseudomembrane surrounding a vascular graft containing clear, sterile fluid. This pathology can be life threatening in some infants due to the mass effect on adjacent mediastinal structures ranging from airway compression to pericardial tamponade. A-10-month-old female was diagnosed with tetralogy of Fallot and pulmonary atresia and underwent a left modified Blalock–Taussig shunt with a 4-mm PTFE graft. Respiratory distress and hypoxia developed requiring intubation several days after the operation. Chest x-ray showed a large and welldemarcated left superior mediastinal mass and pleural effusion (Fig. 1). There was marked tracheal displacement. Echocardiography with color Doppler showed a patent shunt and a large cystic formation encircling the functioning PTFE graft (Fig. 2). On reexamination, a large left pleural effusion due to fluid leakage along the PTFE graft was found and the shunt was surrounded by a fibrous pseudomembrane. Fluid was aspirated and the seroma was evacuated, leading to an increase in oxygen saturation from 40 to 90%. The echocardiographic examination confirmed the disappearance of the fluid collection and patency of the shunt. The postoperative course was uneventful, and the patient was discharged from hospital 5 days later. A second patient was found to have a left mediastinal mass on the second day postoperatively after a left Blalock–Taussig shunt without clinical sequelae. Transthoracic echocardiography showed suspicion of perigraft seroma formation. Computed chest tomography was performed and showed a cystic mediastinal mass surrounding the shunt (Fig. 3). The patient did not require surgical reintervention. Complications of modified Blalock–Taussig shunts include thrombosis, aneurysm formation, hematoma, O.F. Dogan (&) Æ U. Duman Æ U. Ersoy Department of Cardiovascular Surgery, Hacettepe University Medical Faculty, Sihhiye, Ankara, Turkey E-mail: ofdogan@hacettepe.edu.tr