Vedat Yildirim

Does preemptive stellate ganglion blockage increase the patency of radiocephalic arteriovenous fistula

Objective. Radio-cephalic arteriovenous fistulas (AVFs) have high early failure ratio. Increased sympathetic activity and spasm of radial artery during the surgery may responsible for early occlusion rate. Design. Fifty patients were randomized to two groups (each containing 25 patients). Stellate Ganglion Blockade (SGB) was performed in Group 1. Another group was considered as control group (Group 2) to make statistical comparisons. All AVFs were performed under local anesthesia in both groups. Results. Average fistula flow was 201.4±40.4 ml/min in Group 1 and 155.6±27.4 ml/min in Group 2 (p < 0.001). While average peak velocity of radial artery was 167.1±31.3 cm/sec in Group 1, it was 107.8±15.8 cm/sec in Group 2 (p < 0.001). Thrill was found in all Group 1 patients, but there was thrill only 13 of the Group 2 patients (p < 0.001). Mean maturation time was 41.4±6.8 days after surgery in Group 1 and 77.1±10.5 days in Group 2 (p < 0.001). Adequate vascular access was obtained 19 patients in Group 1 and 12 patients in Group 2 (p = 0.041). Conclusion. AVF occlusion rate is much more common in early postoperative period. Diminished sympathetic tonus by preemptive SGB not only increases early patency rate but also increases fistula maturation rate.

Sodium nitrite provides angiogenic and proliferative effects in vivo and in vitro.

Background Angiogenesis is the formation of new blood vessels from pre-existing vasculature. Many factors and substances may stimulate angiogenesis and exhibit proliferative effect. In this study, we aimed to investigate the angiogenic and proliferative effects of sodium nitrite. Material/Methods The angiogenic activity of sodium nitrite was examined in vivo in the chick chorioallantoic membrane (CAM) model and in vitro in tube formation assay of human umbilical vein endothelial cells (HUVECs). The proliferative activity of sodium nitrite was also determined through MTT assay on HUVECs. Results In CAM assay, sodium nitrite had an angiogenic effect especially at high concentrations compared with the control group and this was statistically significant. There was a proliferative effect on HUVECs in the presence of sodium nitrite for 24 and 48 h, and this was statistically significant (p<0.05). Comparing the tube length/area ratio values, there was statistically significant increase in the sodium nitrite group compared to the control group (p<0.05). Conclusions The results provide evidence that sodium nitrite induces angiogenesis in vitro and in vivo.

Combination sedoanalgesia with remifentanil and propofol versus remifentanil and midazolam for elective cardioversion after coronary artery bypass grafting

Postoperative atrial fibrillation (AF) occurs in up to 50% of cardiac surgery patients and represents the most common postoperative arrhythmic complication. Elective cardioversion, a short but painful procedure, remains an option for patients who do not convert to sinus rhythm with medical therapy. Combinations of remifentanil (a potent analgesic with a short elimination time) with propofol (a hypnotic agent) or midazolam (a sedative agent) produce a synergistic interaction. This study was undertaken to compare these combinations in terms of effectiveness and pain relief when given as sedoanalgesia for elective cardioversion. In this prospective, randomized trial, 60 adult patients with postoperative AF after coronary artery bypass grafting were given a single dose of propofol 1 mg/kg combined with remifentanil 0.1 μg/kg (group 1), or midazolam 0.05 mg/kg combined with remifentanil 0.1 μg/kg (group 2). Cardiorespiratory parameters were monitored and recorded. Demographic data were similar (P>.05) and sufficient sedoanalgesia and successful cardioversion were achieved in both groups. Hemodynamic parameters revealed no significant differences between groups (P>.05); however, induction time, time to eye opening, recuperation time, and time to full recovery of psychomotor function were faster in group 1 than in group 2 (P<.05). The remifentanil/propofol combination provided sufficient analgesia, satisfactory hemodynamic stability, and mild respiratory depression, along with faster recovery and discharge times from the intensive care unit.

Is there a role for surgery in the management of isolated secundum atrial septal defect in adults

Summary Objectives The aim of this retrospective study was to compare the short-term outcomes of surgical versus transcatheter closure of secundum atrial septal defect (ASD) in adults. Methods From January 2008 to October 2012, 229 patients aged 18 years and older with significant isolated secundum ASDs were admitted to our hospital. We focused only on objective data obtained from their medical records. We collected and compared a total of 163 patients with isolated secundum ASD, who were treated with device occlusion or surgical closure, and had no missing data. Postoperative outcomes, rhythm disturbances, residual ASD, infection rates and length of hospital stay were compared. Results Complete follow-up data were available for 42 (46%) patients in the device group and for 121 (87%) in the surgery group. Complete closure was observed in 41 of the 42 patients (97.6%) in the device group (p = 0.258) and in all 121 in the surgery group (100 %) (p > 0.05). There were no mortalities. The mean length of hospital stay in the device group was 1.92 ± 0.43 days and in the surgery group 7.14 ± 0.14 days (p < 0.01). Conclusions The transcatheter approach for closure of ASDs is an effective and safe treatment option when performed for certain indications. Broadening the spectrum of indications may cause some adverse events. Surgical treatment remains a good alternative for all patients with ASDs and can be performed safely in order not to increase procedure-related complications.

Preoperative exercise heart rate recovery predicts intraoperative hypotension in patients undergoing noncardiac surgery

STUDY OBJECTIVE To assess the predictive role of heart rate (HR) recovery in the detection of intraoperative hypotension in patients undergoing noncardiac surgery. DESIGN Prospective, observational study. SETTING Department of cardiology and operating rooms of university hospitals. PATIENTS 160 ASA physical status 1 and 2 patients scheduled for elective noncardiac surgery. MEASUREMENTS All patients underwent exercise stress testing. Maximum HRs and metabolic equivalent levels were recorded. Heart rate recovery at the first, second, and third minutes were calculated by subtracting HRs one, two, and three minutes into the recovery period from the maximal HR at peak exercise. A decrease in mean arterial pressure (MAP) of greater than 30% was defined as intraoperative hypotension and recorded. Patients were classified to two groups according to whether they had intraoperative hypotension. MAIN RESULTS Hypotensive episode was observed in 31 patients (19.7%) during the operation. The presence of diabetes mellitus was higher in patients with intraoperative hypotension (22.6% vs 7.1%, P = 0.019). Mean HR recovery at the first, second, and third minutes was significantly lower in the intraoperative hypotension group (P = 0.001, P = 0.004, and P = 0.031, respectively). Heart rate recovery at the first, second, and third minutes was a good predictor of intraoperative hypotension, but only HR recovery at the first minute (OR 0.82, 95% CI 0.73 to 0.92, P = 0.001) and HR recovery at the second minute (OR, 0.90; 95% CI, 0.82 to 0.98; P = 0.019) were independent predictors of intraoperative hypotension. A higher negative correlation was noted between the degree of MAP reduction and HR recovery at the first minute (r = -0.797, P = 0.001). CONCLUSIONS Abnormal preoperative exercise HR recovery predicts intraoperative hypotension in patients undergoing noncardiac surgery. Given the importance of intraoperative hypotension, preoperative use of exercise testing might be considered.

Unrecognized indication for robot-assisted cardiac surgery: Patients with acute psychotic disorders

Abstract Patients with acute psychotic disorders are often considered as inappropriate candidates for cardiac surgery as well as for other surgical interventions. Post-operative care and patient compliance, which are the main problems associated with such patients, are the most important issues for conventional cardiac surgery. Robot-assisted cardiac surgery may be a new solution in this respect. In this report we aimed to present our acute psychotic patient with serious mitral insufficiency secondary to huge atrial myxoma, treated with robotic cardiac surgery.

Platelet indices may be correlated with severity of vasospastic disorders.

Background Vasospastic disorders are common worldwide. In daily practice, routine blood samples are used for several investigations. In this study we aimed to determine the possible correlations between lymphocyte count, platelet indices, and the severity of vasospastic disorders. Material/Methods Data of 102 patients admitted to our department with vasospastic disorder symptomatology were retrospectively collected. Demographic data, symptoms, and blood test results were recorded. Patients were divided into 2 groups according to their rewarming time, which is determined by the cold stimulation test. Group 1 consisted of patients with rewarming time below 20 min and Group 2 consisted of patients with rewarming time above 21 min. Demographic data and blood test results were compared between groups. Results were analyzed with the SPSS for Mac 20.0 package program. Results There was no statistically significant difference between the groups in demographic variables and symptomatology. In Group 2, mean platelet volume (MPV) and platelet distribution width (PDW) were higher than in Group 1, which was statistically significant (8.87±0.74 vs. 8.38±0.78, p=0.001 and 15.91±1.92 vs. 14.7±1.99, p=0.002, respectively). Similar to MPV and PDW, lymphocyte count was also higher in Group 2 than in Group 1 (2.28±0.65 vs. 1.90±0.68, p=0.002). Conclusions Diagnosis and grading the severity of VD is challenging, but it can be supported by the presence of increased PDW, MPV, and lymphocyte count.