Yunus Nazli

Preoperative Neutrophil–Lymphocyte Ratio and Saphenous Vein Graft Patency After Coronary Artery Bypass Grafting

Aim: The aim of the present study was to investigate the predictive value of preoperative neutrophil–lymphocyte ratio (NLR) in postoperative saphenous vein graft patency in patients undergoing coronary artery bypass grafting (CABG) surgery. Method: We retrospectively analyzed 444 patients who had undergone CABG and a further control coronary angiography due to recurrence of symptoms. The patients were divided into tertile groups according to the NLR. The primary end point was 50% saphenous vein graft stenosis or more or complete occlusion. Result: The saphenous vein graft failure in the 3 groups based on NLR was 33%, 66.2%, and 79.1%, in the low-, middle- and high-risk groups, respectively. In multivariate regression modeling, current smoker, diabetes mellitus, target artery diameter <1.5 mm, and NLR independently predicted saphenous vein graft patency in patients after CABG. Conclusion: Preoperative NLR is clearly an independent predictor of saphenous vein graft patency in patients after CABG.

Effect of topical N-acetylcysteine in the prevention of postoperative pericardial adhesion formation in a rabbit model.

BACKGROUND N-acetylcysteine (NAC), a precursor of reduced glutathione, has been in clinical use primarily as a mucolytic. In addition, NAC is well known for their free radical scavenging and antioxidant properties. Increasing of reactive oxygen products occurring during cardiac surgery can play an important role in postoperative adhesion formation. We investigated to the efficacy of the NAC for postoperative pericardial adhesions. METHODS Sixteen New Zealand white rabbits (2.5-3 kg) were used and categorized into two groups including study (use of NAC) and control groups. In both groups, the pericardium was opened longitudinally, and the exposed epicardial surfaces were abraded with dry gauze. The rabbits were divided into two groups: Group 1 was treated with the sponge, which impregnated with NAC solution, (10%, 300 mg/3 ml) and applied over the abraded epicardium for 5 min (n=8). Group 2 was the control, and the sponge, which was impregnated with 3-ml isotonic NaCl solution (0.9%), was applied onto the surface of the abraded epicardium for 5 min (n=8). After a period of 2 weeks, the animals were sacrificed. The scores of adhesion were graded by macroscopic examination, and the pericardial tissues were analyzed microscopically in point of inflammation and fibrosis. RESULTS In Group 1, the adhesion scores were significantly lower compared with the control group [Group 1 vs. 2; 1 (1-2) vs. 3 (2-3), P<.001]. No significant difference was found between the groups in terms of the severity of inflammation [Group 1 vs. 2; 1.5 (1-3) vs. 2.5 (1-3), P=.083]. There was a difference between groups in terms of the degree of fibrosis [Group 1 vs. 2; 2 (1-2) vs. 3 (2-3), P=.007]. CONCLUSIONS The use of NAC for preventing postoperative pericardial adhesions was reduced to adhesion and fibrosis scores in an experimental rabbit model. There was no statistically significant difference between groups in terms of inflammatory scores. The NAC effectively prevented the formation of pericardial adhesion.

Cilostazol Attenuates Spinal Cord Ischemia-Reperfusion Injury in Rabbits

OBJECTIVE The aim of this study was to evaluate the pretreatment effect of cilostazol on spinal cord ischemia-reperfusion injury. DESIGN Prospective, interventional study. SETTING Research laboratory, single institution. PARTICIPANTS Twenty-four New Zealand white rabbits. INTERVENTIONS Twenty-four rabbits were divided into 3 equal groups: group I (sham), group II (ischemia-reperfusion, control group), and group III (cilostazol, administered orally 30 mg/kg/day for 3 days before the surgery). Spinal cord ischemia was induced by clamping the aorta both below the left renal artery and above the iliac bifurcation for 30 minutes. Seventy-two hours postoperatively, the motor function of the lower limbs was evaluated in each animal according to the modified Tarlov score. Spinal cord and blood samples were taken for histopathologic and biochemical analyses at the 72nd hour of reperfusion. MEASUREMENTS AND MAIN RESULTS All rabbits in the ischemia-reperfusion group (group II) showed severe neurologic deficits. The median (IQR) Tarlov scores postoperatively at 72 hours in groups I, II, and III were 5.0(-), 2.0(1.0), and 4.5(1.0), respectively. Administration of cilostazol resulted in a significant reduction in motor dysfunction when compared with the ischemia-reperfusion group (p<0.001). In the ischemia-reperfusion group, serum and tissue glutathione peroxidase and superoxide dismutase activity were significantly less compared with the sham group (group I) (p<0.05). Serum and tissue glutathione peroxidase and superoxide dismutase levels in the cilostazol-treated group (group III) were higher compared with the ischemia-reperfusion group (p<0.05). In the cilostazol-treated group, serum and tissue malondialdehyde levels were lower compared with the ischemia-reperfusion group (p<0.05). Histopathologic analysis found decreased neuronal injury in the cilostazol group when compared with the ischemia-reperfusion group (p< 0.05). CONCLUSIONS This study showed that pretreatment with cilostazol significantly ameliorated neurologic functional outcome and attenuated neuronal histopathologic injury after transient aortic occlusion in rabbits.

Neuroprotective effect of atorvastatin in spinal cord ischemia-reperfusion injury

OBJECTIVES: Prevention of the development of paraplegia during the repair of the damage caused by descending thoracic and thoracoabdominal aneurysms remains an important issue. Therefore, we investigated the protective effect of atorvastatin on ischemia-induced spinal cord injury in a rabbit model. METHOD: Thirty-two rabbits were divided into the following four equally sized groups: group I (control), group II (ischemia-reperfusion), group III (atorvastatin treatment) and group IV (atorvastatin withdrawal). Spinal cord ischemia was induced by clamping the aorta both below the left renal artery and above the iliac bifurcation. Seventy-two hours postoperatively, the motor function of the lower limbs of each animal was evaluated according to the Tarlov score. Spinal cord and blood samples were obtained for histopathological and biochemical analyses. RESULTS: All of the rabbits in group II exhibited severe neurological deficits. Atorvastatin treatment (groups III and IV) significantly reduced the level of motor dysfunction. No significant differences were observed between the motor function scores of groups III and IV at the evaluated time points. Light microscopic examination of spinal cord tissue samples obtained at the 72nd hour of reperfusion indicated greater tissue preservation in groups III and IV than in group II. CONCLUSION: This study demonstrates the considerable neuroprotective effect of atorvastatin on the neurological, biochemical and histopathological status of rabbits with ischemia-induced spinal cord injury. Moreover, the acute withdrawal of atorvastatin therapy following the induction of spinal cord ischemia did not increase the neuronal damage in this rabbit model.

Assessment of the efficacy of Ankaferd blood stopper on the prevention of postoperative pericardial adhesions.

Summary Objectives Ankaferd has been used as a blood-stopping agent and it may also have an anti-inflammatory effect. We investigated the efficacy of Ankaferd in preventing postoperative pericardial adhesions in an experimental rabbit model. Methods Sixteen New Zealand white rabbits were used and categorised into two groups: an Ankaferd and a control group. The Ankaferd group of rabbits was treated with a sponge impregnated with Ankaferd solution, which was applied over the abraded epicardium. A sponge impregnated with 0.9% isotonic NaCl solution was applied to the control group using the same protocol. Scores for adhesion and visibility of coronary vessels were graded by macroscopic examination, and pericardial tissues were analysed microscopically in terms of inflammation and fibrosis. Results In the Ankaferd group, the adhesion scores were significantly higher than in the control group (p = 0.007). When the groups were compared according to the prevalence of fibrosis and degree of inflammation, the Ankaferd group was found to be statistically significantly different from the control group in terms of prevalence of fibrosis (p = 0.028). Conclusion Topical application of Ankaferd to prevent postoperative pericardial adhesions increased adhesion and fibrosis scores.

Leucocytoclastic vasculitis associated with clopidogrel

Editor, Clopidogrel, a thienopyridine derivative, is an antiplatelet agent that inhibits platelet aggregation by blocking the adenosine diphosphate receptor that is responsible for initiating platelet adhesion and aggregation. Currently, clopidogrel is mainly used for prevention of coronary artery disease and for the early and longterm prevention of atherothrombotic events (1,2). We report a case of leucocytoclastic vasculitis (LCV) associated with clopidogrel treatment. To the best of our knowledge, there is no other report of LCV related to clopidogrel treatment in English literature. Treatment with clopidogrel was initiated in a 45 yearold-man after insertion of a stent following acute inferior myocardial infarction. High-dose clopidogrel was given as a total first day dose of 600 mg followed by a dose of 75 mg daily. Four days after starting the clopidogrel therapy, painful cutaneous eruptions appeared on the lower legs including palpable purpura and ecchymosis (Figure 1A, 1B, and 1C). He had undergone a previous coronary artery bypass grafting (CABG) surgery using the left internal mammary artery to the left anterior descending (LAD) coronary artery 7 years ago. Because of the critical coronary lesions and the clinical status, it was decided to perform an elective CABG re-operation. The patient was under treatment of oral acetylsalicylic acid (100 mg), metoprolol (50 mg), atorvastatin (20 mg) and ramipril (2.5 mg) once daily for 7 years. He denied the use of any other medication. He had no previous history of adverse effect to any drug. He had no complaints of arthralgia or abdominal pain. Physical examination showed palpable purpura and ecchymosis on the lower legs. Blood cell count, serum biochemistry, urine analysis, coagulation profile, whole autoantibodies (antinuclear antibody, extractable nuclear antigen, antineutrophil cytoplasmic antibody, anticardiolipin antibody IgM, and antiphospholipid antibodies), complement (C3, C4), and cryoglobulins were all normal. Microscopic examination of hematoxylin-eosin stained sections of the skin biopsy specimen showed degenerated epidermis, perivascular lymphocytic infiltrate and some eosinophils in the superficial and deep dermis, fibrinoid necrosis and leucocytoclasia (Figure 2). Cutaneous vasculitis was diagnosed with clinical and histopathological findings. Then clopidogrel was discontinued. Because he had critical coronary artery disease, his other medications were continued even after the development of the vasculitis. His skin lesions resolved within 7 days after discontinuation of the clopidogrel and disappeared completely in 2 weeks without the need of specific therapy. Two weeks after, we successfully performed triple on-pump redo-CABG operation with saphenous vein grafts (to the LAD, the circumflex artery, right coronary posterior descending artery) in the patient. After an uneventful postoperative course, the patient was discharged on the seventh postoperative day. The antiplatelet drug clopidogrel is an oral thienopyridine derivate that has been extensively used for treatment and secondary prevention of variety of cardiovascular disease. Although clopidogrel is well tolerated by most patients, rare but serious hypersensitivity reactions including urticaria, skin rashes and angioedema have been reported (3). Documented adverse effects associated with clopidogrel treatment include gastrointestinal complaint, thrombotic thrombocytopenic purpura, neutropenia, asthma, and hepatotoxicity (1,3). letter to the editor

Brachial artery transection associated with open elbow dislocation in a 12-year-old: a case report

Although acute elbow dislocations are common orthopedic injuries, concomitant neurovascular injury is rare. Brachial artery transection can result from open elbow dislocation and responds well to vascular repair. Rapid evaluation and a high level of suspicion are essential to facilitate immediate treatment. Delay to identify vascular injury after elbow dislocation or reduction can potentially lead to limb ischemia, and potential loss of limb. We present a case of relatively rare transection of the brachial artery, with an accompanying traumatic open elbow dislocation in a 12-year-old boy.

The Effect of Mitomycin-C in Reducing Pericardial Adhesion After Cardiac Surgery in Rabbits

BACKGROUND Mitomycin-C has been in clinical use primarily as a chemotherapeutic agent and is well known for antifibrotic properties. It has been widely used to prevent postoperative fibroblast proliferation and reduce scar adhesion in ophthalmologic and otolaryngologic operations. We investigated the efficacy of mitomycin-C in reducing postoperative pericardial adhesions in a rabbit model. METHODS New Zealand white rabbits were used and categorized into 2 groups, study (use of mitomycin-C) and control. Group 1 (n = 8) was treated with a sponge impregnated with mitomycin-C solution that was applied over the abraded epicardium. In group 2 (control group), the sponge was impregnated with 0.9% isotonic NaCl solution and was applied with the same protocol as the mitomycin-C-impregnated sponge in group 1 (n = 8). Rabbits were humanely killed at a mean of 2 weeks. The scores of adhesion were graded by macroscopic examination, and the pericardial tissues were analyzed microscopically in terms of inflammation and fibrosis. RESULTS In group 1, the adhesion scores were significantly lower than the control groups. No significant difference was found between the groups in terms of the severity of inflammation. There was a difference between groups in terms of the degree of fibrosis. CONCLUSIONS The use of mitomycin-C to prevent postoperative pericardial adhesions reduced adhesion and fibrosis scores in an experimental rabbit model. However, efficacy in reducing inflammation was not demonstrated.

Thyroid vein thrombosis in a young woman with methylenetetrahydrofolate reductase gene mutation receiving cyproterone acetate/ethinylestradiol treatment for polycystic ovary syndrome: a case report.

Thyroid vein thrombosis is a rare variety of venous thrombosis. The use of oral contraceptives and heterozygous methylenetetrahydrofolate reductase (MTHFR) gene mutation could have synergistic effects on the onset of venous thromboembolism. We report a 28-year-old woman with thyroid vein thrombosis. The thrombosis was possibly provoked by a combination of heterozygous MTHFR gene mutation and the use of a combined oral contraceptive (COC) containing cyproterone acetate/ethinylestradiol (CPA/EE) for polycystic ovary syndrome (PCOS). The patient was treated successfully with low molecular weight heparin and oral anticoagulation. The thyroid vein thrombosis resolved and the patient was advised to maintain lifelong use of anticoagulation therapy. Our report emphasizes that the combination of heterozygous MTHFR gene mutation, PCOS, and the use of a COC-containing CPA/EE could increase risk of thyroid vein thrombosis in young adults.

Synovial sarcoma in the right atrium and right ventricle

A metastatic synovial sarcoma in the right atrium and ventricle is described. A 36-year-old man was admitted to our hospital with generalized fatigue, dyspnoea, and precordial pain. Transthoracic echocardiography demonstrated a metastatic tumour in both the right atrium and right ventricle and revealed obstruction of the infl ow tract of the right ventricle caused by a metastatic right atrial tumour. Thoracic computed tomography revealed a pleural-based paravertebral mass in the left intrathoracic cavity and multiple pulmonary nodules in both lungs. Cardiac surgery was performed for palliative treatment due to right cardiac failure and a risk of fatal embolization. The patient died 12 months after the cardiac surgery.