Management of chylothorax with octreotide after congenital heart surgery.

OBJECTIVE: Chylothorax is a rare complication of congenital cardiac surgery that can seriously impair the postoperative course unless treated properly. We present our treatment protocol and results with octreotide, a somatostatin analogue, in cases of chylothorax following congenital heart surgery. MATERIAL AND METHODS: Between March 2006 and December 2009, 12 patients were treated for chylothorax following congenital cardiac surgery. Patients consisted of five females and seven males, with a mean age of 16.6 months (7 days - 36 months). Octreotide was administrated as a continuous intravenous infusion with a dosage of 4-10 µg/kg/h. RESULTS: Chylothorax was successfully resolved in an average of 10.3 days (7-14 days) with octreotide infusion and a strict oral diet containing medium-chain triglycerides. At a mean follow-up of 9.4 months (1-35), all patients are doing well, without any recurrence of chylothorax. CONCLUSION: Octreotide, a long-acting somatostatin analog, is an effective and safe agent for the treatment of postoperative chylothorax and warrants further investigation in a larger series with a greater number of patients.

Surgery-related complications in cardiac transplantation patients.

OBJECTIVE: The surgical techniques was first described by Lower and Shumway for cardiac transplantation have not changed for many years; they are still being commonly used worldwide despite recently presented alternatives. We sought to evaluate the surgical complications among our cardiac transplantation patients in whom we performed the standard technique. PATIENTS AND METHODS: The standard biatrial anastomosis technique was used in 13 patients who have a mean follow-up of 18.6 (1 to 38) months. During the follow-up, echocardiographic assessment was performed to evaluate left and right atrial diameters, tricuspid and mitral valve regurgitation, interatrial septum, and suture lines. Elecotrocardiograms were evaluated for arryhthmia and pacemaker requirements in the midterm. RESULTS: The mean left and right atrial diameters were measured as 40.5 (32 to 57) x 66.6 (48 to 78) and 37.9 (32 to 43) x 56.3 (48 to 69) mm, respectively. The jet area was calculated at less than 5 cm(2) for mitral and tricuspid valve regurgitation, which can be defined as "mild" regurgitation. There was no increase in the degree of regurgitation of both atrioventricular valves during the follow-up period. In one patient, a thrombus was detected in the suture line; there was a nonsignificant left to right shunt in another patient. A temporary pacemaker was indicated in two patients. Atrial fibrillation was detected in three patients, who responded to medical therapy. During the follow-up atrial fibrillation developed in one patient. CONCLUSION: The cardiac transplantation operation using the standard technique may result in atrial dysfuntion due to deformation of atrial integrity and geometry. However, when we evaluated our results, we concluded that the standard surgical technique was a safe, simple, effective, and feasible method.

The midterm results of cardiac transplantation patients.

OBJECTIVE: Cardiac transplantation is an important treatment option that increases the survival and decreases the limitations in effort capacity among patients with end-stage heart disease. In this study we have presented the midterm results of 13 patients who underwent cardiac transplantation between 2003 and 2007. PATIENTS AND METHODS: There were 10 male and three female patients of mean age of 32 +/- 13.27 years (12 to 54). In one patient, we performed combined cardiac and renal transplantation. Ischemic cardiac disease was present in six patients and cardiomyopathy in seven patients. The mean age of the donors was 23.3 +/- 11.8 years (12 to 46). Corticosteroids, cyclosporine, and mycophenolate mofetil were used for immunosuppression. Sirolimus was employed in five cases due to impaired renal function. Patients were followed by echocardiography, endomyocardial biopsy, and dobutamine stress echocardiography. RESULTS: The mean follow-up was 18.6 +/- 13.4 (1 to 38) months. In four patients, there was grade IIIA (II-R) rejection. In five patients, tacrolimus or cyclosporine was replaced with sirolimus due to elevated creatinine levels. Dobutamine stress echocardiography was positive in one patient, who displayed a severe left main coronary artery lesion. There was no operative mortality. There was only one hospital mortality (7.6%). Two patients died in the midterm. The overall mortality on follow-up was 3 (23.1%). The survival rates in the first, second, and third years were 92%, 88%, and 75%, respectively. Ejection fraction were more than 50%; all of posttransplant survivors showed good effort capacity. CONCLUSION: Cardiac transplantation is a definitive, safe, and effective treatment for patients with end-stage heart failure.

Massive ascites due to right heart failure after cardiac transplantation and its treatment: a case report.

Ascites is a common clinical condition during right heart failure. In this short report we have presented a patient with massive ascites due to right heart failure after cardiac transplantation who was previously operated for Ebstein's anomaly and pulmonary stenosis as well as mitral and tricuspid valve repairs. Right heart failure increases the accumulation of ascites which decreases the preload of the heart and cardiac output. Aggressive paracentesis may be a definitive solution for this type of patient.

The impact of renal failure on survival following cardiac transplantation.

OBJECTIVE: Renal failure after cardiac transplantation is a common and serious complication. In this study we investigated the incidence and effects of renal failure on survival among patients who underwent cardiac transplantation. PATIENTS: Eight patients underwent cardiac and one patient combined cardiac and renal transplantation. The mean age of the patients was 33 +/- 11.6 years (range, 17 to 51). On preoperative echocardiographic evaluation, the mean ejection fraction was calculated as 19 +/- 3.11% (range, 16% to 24%). One patient had compensated renal failure and one patient, dialysis-dependent renal failure. Hemofiltration was routinely used during the operations. Corticosteroids, cyclosporine, and mycophenolate mofetil were used for immunosuppression. Early renal replacement therapy was performed in patients with acute renal failure. RESULTS: The incidence of acute renal failure was 55.5% (5 patients). In the early postoperative and follow-up periods, the mean ejection fraction was 55 +/- 9.9% and 57 +/- 4.5%, respectively. The mean follow-up period was 21.3 +/- 8.8 (range, 6 to 33) months. In the early initiation period, the mean peak value of cyclosporine blood level was 479 +/- 201.8 ng/mL during the first month, 250 +/- 95.3 and after the third month, 195 +/- 43.7 ng/mL. The mean creatinine level at last follow-up was 1.27 +/- 0.4. One patient experienced a grade III-A rejection episode. One patient died due to coronary artery occlusive disease at 31 months after transplantation. COMMENT: In our study we have observed that renal failure had no negative effect on patient survival. This can be explained by improved cardiac performance, keeping cyclosporine levels low finding and utilizing early renal replacement treatment.

Xenograft transplantation in congenital cardiac surgery at Baskent University: midterm results.

OBJECTIVE: Xenograft valved conduits have been used in several cardiac pathologies. In this study we have presented our midterm results of pediatric patients pathologies who were operated with xenograft conduits. PATIENTS AND METHODS: Between January 1999 and January 2005, 134 patients underwent open heart surgery with xenograft conduits. The conduits were used to establish the continuity of the right ventricle to the pulmonary artery or aorta, the left ventricle to the pulmonary artery, or aorta due to various types of complex cardiac anomalies. Patients were evaluated by transthoracic echocardiography (ECHO) at 6-month follow-ups. Cardiac catheterization was performed when ECHO demonstrated significant conduit failure. RESULTS: Hospital mortality was observed in 28 patients (20.1%), and 13 patients died upon follow-up (9.7%). Mean follow-up was 24.6 +/- 4 months (range, 13 to 85 months). Among 93 survivors 20 patients (21.5%) were reoperated due to conduit failure. The main reasons for conduit failure were stenosis (n=13), valvular regurgitation (n=2), or both conditions in 5 cases. Mean pulmonary gradient before conduit re-replacement was 47.7 +/- 30.1 mmHg. The 1-, 3-, and 6-year actuarial survival rates were 95 +/- 2%, 91 +/- 3%, and 86 +/- 5%. The 1-, 3-, and 6-year actuarial freedom rates from reoperation were 95 +/- 1%, 90 +/- 3%, and 86 +/- 4%. An increased gradient between the pulmonary artery and the right ventricle and prolonged cardiopulmonary bypass times were observed to be significant risk factors for reoperation. There was no mortality among reoperated patients. CONCLUSION: Xenograft conduits should be closely followed for calcification and stenosis. Conduit stenosis is the major risk factor for reoperation. In these patients, reoperation for conduit replacement can be performed safely before deterioration of cardiac performance.

Our experience in cardiac transplantation in Baskent University.

Recently cardiac transplantation has an important place in treatment of end-stage cardiac failure. In Turkey between 2003 and 2005 at 10 centers 64 cardiac transplantations were performed including five at our facility. Herein we have presented our results. All patients were men of mean age 34.2 +/- 10.7 (17 to 44) years. Upon preoperative echocardiography their mean ejection fraction was 18% +/- 3.27% (17% to 23%). Pulmonary vascular resistance was 4.47 wood unit in one patient and in one case, there was Rh incompatibility between donor and recipient. We used HTK solution for protection of donor hearts. Mean ischemia time was 251.2 +/- 62.7 minutes (155 to 314). Mean aortic clamping time was 84 +/- 4.7 minutes (80 to 90). In all patients we performed a biatrial anastomosis technique. Hemofiltration was used to prevent hemodilution during operation. In the postoperative period four patients had acute renal dysfunction; one, a minor cerebrovascular accident; two, reoperated because of bleeding; one, cholestasis; one, temporary atrio-ventricular block; and one, mediastinitis. Mean follow-up time was 15.6 +/- 19.7 months (2 to 50). Neither early nor late mortality has occurred. All patients are in New York Heart Association class I. In all cases we used triple immunosuppressive therapy. In the follow-up period the mean number of cardiac biopsies per patient was 4.2 +/- 3.03 (2 to 8). Two cases had cardiac catheterization. As a complication of cardiac biopsy, pericardial tamponade developed in one patient; in another one we observed a right ventricular aneursym after cardiac biopsy. Cardiac transplantation was performed with low mortality and morbidity rates in end-stage cardiac failure patients with longer life expectancy and higher life quality. Unfortunately in our country, because of difficulties to find donor hearts, cardiac transplantations were small in number. For better results, we need a larger series.

Evaluation of the potential role of echocardiography in the detection of allograft rejection in heart transplant recipients.

PURPOSE: Our objective was to determine the most relevant systolic and diastolic echocardiographic parameters to detect left ventricular (LV) dysfunction associated with allograft rejection among heart transplant recipients. PATIENTS AND METHODS: Seven consecutive recipients underwent serial echocardiographic studies with two-dimensional spectral Doppler and tissue Doppler (TD) according to our institutional protocol. Results were compared with clinical status and endomyocardial biopsies (EMB) whenever available. RESULTS: The time since transplantation was 22 to 850 days. Patient no. 2 had a biopsy-proven acute rejection at the 11th week which was associated with decreased TD velocities, ejection fraction (EF), and stroke volume (SV), as well as increased pericardial effusion and posterior wall thickness. Interestingly, changes in TD parameters preceded those in EF and SV. However, similar but less remarkable changes in TD velocities, EF, SV, pericardial effusion, and posterior wall thickness also occurred during other events, such as systemic infection and immediate postoperative hemodynamic compromise despite no rejection. A biopsy performed 7 months later in a patient with a previous rejection episode due to a relatively low EF and SV as well as increasing pericardial effusion with normal TD velocities revealed no rejection. CONCLUSIONS: These data suggest that echocardiographic findings, although not specific for acute rejection, may play a potential role as a screening test to exclude rejection in heart transplant recipients.

Low-dose histidine-tryptophan-ketoglutarate solution for myocardial protection.

The effect of histidine-tryptophan-ketoglutarate (HTK) solution for myocardial protection has been shown in experimental and clinical studies using long ischemic times and high dosages. In our study we compared myocardial protection in isolated coronary bypass with a short period of ischemia using low dosage HTK and cold crystalloid cardioplegia. Each group contained 21 coronary artery disease patients. Cardioplegic solutions were administered antegrade in 10 to 15 mL/kg in one shot. This dosage of HTK was lower than that mentioned in the literature. We measured malondialdehyde, lactate, creatine kinase, creatine kinase-MB, and troponin-I levels. Aortic clamping time in the HTK group 33.9 +/- 8.2 minutes, versus 36.2 +/- 11.3 minutes in the crystalloid cardioplegia group (P > .05). Levels of creatine kinase and malondialdehyde were lower in HTK group at 24 hours and 2 minutes, respectively. Lactate levels were lower in the crystalloid cardioplegia group at 2 minutes in the coronary sinus serum sample, but there were no statistically differences among ischemic serum markers in both groups. Only intervals between aortic clamping and cardiac arrest were statistically meaningful (HTK 63.3 +/- 14.7 seconds versus crystalloid cardioplegia 53.6 +/- 15.6 seconds, P = .044). Our study shows that use of low-dose HTK for short clamping time operations is as successful for myocardial protection as crystalloid cardioplegia. Longer times for fibrillation can be explained with the low levels of potassium in HTK solution, but this length did not cause a biochemical or clinical difference.

Systemic inflammatory response related to cardiopulmonary bypass and its modification by methyl prednisolone: high dose versus low dose.

The objective of our study was to investigate the safety and efficacy of high-dose methyl prednisolone (MP) in modifying the systemic inflammatory response (SIR) to cardiopulmonary bypass (CPB) and to compare its efficacy with low-dose MP in children undergoing cardiac surgery for congenital heart disease. Thirty children with congenital heart disease undergoing CPB were randomly assigned to two groups: group 1 (n = 15) received 30 mg/kg MP by an intravenous infusion for 30 minutes and group 2 (n = 15) received 2 mg/kg intravenously, before the onset of CPB. Postoperative clinical parameters were recorded, and serum interleukin (IL)-6 and 8 levels, acute phase reactants, and blood biochemistry were determined serially for both groups. In both groups plasma IL-6 and 8 levels were elevated above the preoperative levels at 2 and 24 hours after declamping. The peak levels were obtained at 2-hour samples. The difference between the two groups in terms of postoperative IL-6 and 8 levels was not statistically significant. C-reactive protein (CRP) levels and polymorphonuclear leukocyte counts, postoperative core temperature, duration of mechanical ventilation, period of stay in intensive care unit, oxygenation indices, and biochemical parameters of patients did not significantly differ in the two groups. Only 1 patient in group 1 had elevated liver enzymes, blood urea nitrogen, and creatinine in the postoperative period. No significant complications were observed due to treatment with high-dose MP. Although postoperative IL and CRP levels indicated a SIR in our patients, the clinical picture was apparently affected in only 1 patient and she was in the high-dose MP group. CPB initiates a SIR that is associated with an increase in neutrophil count, CRP, and IL-6 and 8 levels. High-dose (30 mg/kg) MP was not superior to low-dose (2 mg/kg) in blunting the SIR to CPB in pediatric patients undergoing open-heart surgery.

The role of pulmonary artery anatomy in repair of tetralogy of Fallot.

Pulmonary artery anatomy is the key factor that determines the type of surgical treatment required in tetralogy of Fallot. Despite the fact that routine primary repair is now done on infants, inadequate pulmonary artery size can dictate the need for staged surgical repair in even the oldest age groups. From October 1986 to October 1998, 361 patients at our clinic underwent surgery to correct tetralogy of Fallot. A total of 292 cases were treated with primary repair, 69 surgeries were palliative, and 30 of these 69 underwent corrective surgery. The Nakata index was used as a pulmonary artery index (PAI), and PAI< 200 was the criterion for requirement of two-stage repair. Of the 30 patients that underwent staged repair, the Blalock-Taussig shunt (BTS) procedure was used in 24; the remaining six patients had right ventricular outflow tract reconstruction (RVOTR). The mean age of all the palliative surgery patients was 3.4 years (range 6 months to 11 years), and of those who received corrective surgery was 5.5 years (range 2-12 years). These patients' PAI values were 181 +/- 37.5 mm2/m2 and 359 +/- 130.7 mm2/m2, respectively. The period between the two operations ranged from two months to four years. Mortality rates were 2.8 percent for palliative surgery as a whole, 4.1 percent for primary repair, and 16.6 percent for staged repair. Our policy with regard to corrective surgery for tetralogy of Fallot is to do primary repair regardless of a patient's age and weight, except in cases where the pulmonary artery anatomy is appropriate for the patient's body size.

Two discrete masses of leiomyomatosis in a patient, one extending to the right atrium.

Leiomyomatosis extending to the right side of the heart through the inferior vena cava (IVC) is an extremely rare neoplasm. Although it is pathologically classified as a benign neoplastic formation, its growth and recurrence rate makes its extirpation mandatory. In this case report, we describe a 57-year-old woman who presented with leiomyotosis extending from the IVC to the right atrium (RA). This patient had presented with uterine leiomyoma three years previously. The patient died in the operating theatre from hemostatic problems after surgical complications arising from the unexpected presence of a second tumor.

Atrial fibrillation after coronary artery bypass surgery: P wave signal averaged ECG, clinical and angiographic variables in risk assessment.

BACKGROUND: Atrial fibrillation (AF) is a commonly encountered arrhythmia and occurs in up to 40% of patients after coronary artery bypass surgery (CABG). The preoperative signal averaged ECG (SAECG) P wave may be useful indicator of AF after CABG. We prospectively analyzed the predictive value of SAECG P wave compared to clinical variables. METHODS: Fifty-three patients with coronary artery disease undergoing first elective CABG were enrolled. All patients had P wave specific SAECG, standard 12 lead ECG, ejection fraction and left atrial posteroanterior diameter from the echocardiogram within the 24 h before surgery. From the SAECG P wave, filtered P wave duration was measured. Lead II P wave duration, left atrial enlargement and left ventricular hypertrophy were determined from standard ECG. Patients were continuously monitored during their postoperative period and serial ECGs were taken. RESULTS: During an observation period of up to 16 days, 19 (35.8%) patients developed AF 2.8+/-1.3 days after CABG. Patients with AF more often had left atrial enlargement (LAE) on ECG (P = 0.041) and right coronary artery (RCA) lesion (P = 0.0034). The filtered P wave duration on the SAECG was significantly longer in the AF patients than those without AF (129.7+/-13.2 ms versus 113.9+/-9.0 ms, P = 0.001). Logistic regression analysis identified independent predictors, estimated adjusted relative risk (95% confidence interval) of AF: with LAE, the relative risk was 2.72 (1.13-5.82), RCA lesion, the relative risk was 3.06 (1.45-6.45) and SAECG P wave duration >122.3 ms, the relative risk was 4.58 (2.11-9.97). The occurrence of AF was predicted by electrocardiographically determined left atrial enlargement with a sensitivity of 36%, specificity of 88%, positive predictive accuracy of 63%, negative predictive accuracy of 71%. If presence of right coronary artery lesion was evaluated these values were 63%, 79%, 63%, 79% subsequently. P wave duration >122.3 ms had a sensitivity of 68%, specificity of 88%, positive predictive accuracy of 76%, negative predictive accuracy of 83%. If both P wave >122.3 ms and presence of right coronary artery lesion were combined, these values were 47%, 94%, 81%, 76% subsequently. CONCLUSION: The predictors of AF after CABG were left atrial enlargement on standard 12 lead ECG, RCA lesion and SAECG P wave duration. Among these predictors, SAECG P wave duration was the best predictor of AF after CABG.

The comparison of the responsiveness of human isolated internal mammary and gastroepiploic arteries to levcromakalim: an alternative approach to the management of graft spasm.

AIMS: We studied the effectiveness of levcromakalim, a potassium channel opener (KCO), in the prevention and reversal of spasm in arterial grafts used in coronary artery bypass operations, namely, internal mammary artery (IMA) and gastroepiploic artery (GEA). METHODS: Spasm was mimicked in vitro in arterial rings from 109 patients by increasing the vascular tension with noradrenaline, the thromboxane analogue U46619, endothelin-1 and K+. RESULTS: GEA displayed considerably higher contractile force to these agents than IMA. Pretreatment with levcromakalim depressed significantly the maximal contractile responses (either absolute or relative) to noradrenaline and U46619 but did not affect those of endothelin-1 and K+ in both of the arteries. Sensitivities (to all agents, except to endothelin-1) decreased significantly after levcromakalim. In experiments evaluating the antispasmodic activity of levcromakalim, a higher relaxant capacity was observed in GEA than IMA (for K+ contraction; IMA: 31.32 +/- 3.83%, n= 13 vs GEA: 98.01 +/- 0.71%, n=7, P<0.05). This different activity of levcromakalim between two arterial grafts was apparent even when GEA rings were contracted to higher force (g) than that of IMA (for K+ contraction; GEA: 72.56 +/- 4.96%, n = 7). Responses to levcromakalim were similar in IMA and GEA when endothelin-1 was used as the spasmogenic agent (IMA: 80.98 +/- 4.85%, n=10 vs GEA: 91.93 +/- 3.17%, n=7, P>0.05). CONCLUSIONS: Our results provide evidence that levcromakalim may have a therapeutic value in the treatment of spasm of coronary artery bypass grafts, especially GEA.

The comparison of vascular reactivities of arterial and venous grafts to vasodilators: management of graft spasm.

Graft spasm in the perioperative or postoperative period increases the risk of morbidity and mortality after coronary revascularization and hence necessitates urgent treatment. We have studied the effects of various vasodilators against noradrenaline- and endothelin-1-induced spasms in saphenous vein, internal mammary artery and gastroepiploic artery. In internal mammary and gastroepiploic arteries, the nitrovasodilators, sodium nitroprusside and glyceryl trinitrate, effectively reversed the spasms induced either with noradrenaline (for sodium nitroprusside; internal mammary artery: 101.07% +/- 1.63%; gastroepiploic artery: 94.10% +/- 2.07%) or endothelin-1 (for sodium nitroprusside; internal mammary artery: 97.67% +/- 4.94%; gastroepiploic artery: 90.69% +/- 2.61%). However, in saphenous vein contracted with endothelin-1, the responsiveness to nitrovasodilators was significantly blunted (for sodium nitroprusside: 52.33% +/- 5.19%) than that of rings contracted with noradrenaline (for sodium nitroprusside: 95.04% +/- 1.94%). Both arterial and venous grafts exhibited moderate beta-receptor function in response to isoproterenol. Isoproterenol was less effective in inhibiting the contractions of endothelin-1 in saphenous vein and gastroepiploic artery but not in internal mammary artery. On the other hand, nifedipine and papaverine were fully effective in reversing all the spasms in three of the graft materials. From these results, it can be deduced that saphenous vein is refractory against cyclic guanidine monophosphate (cGMP)-dependent and beta-receptor mediated relaxations when endothelin-1 was used as the spasmogenic agent. Internal mammary artery is the most responsive graft material to the vasodilators regardless of the nature of spasmogenic stimulus. Gastroepiploic artery exhibits functional similarity with internal mammary artery, with the exception of beta-receptor responsiveness.

Endothelial function of human gastroepiploic artery in comparison with saphenous vein.

OBJECTIVE: Endothelial function is one of the important determinants of patency rate of a graft material used in coronary revascularisation. The aim of this study was to compare the endothelial reactivity of human gastroepiploic artery versus saphenous vein in response to various vasoactive substances. METHODS: Gastroepiploic artery and saphenous vein rings were mounted in an organ bath containing Krebs-Ringer bicarbonate solution aerated with 95% O2 and 5% CO2 at 37 degrees C. Endothelium dependent responses of acetylcholine, histamine, and bradykinin were examined on the precontracted rings of the vessels. The sensitivity of these two graft materials to the potent vasoconstrictor agent endothelin-1 was also compared. RESULTS: Acetylcholine, histamine, and bradykinin caused dose dependent relaxations in saphenous vein and gastroepiploic artery rings. These agonists were more effective in producing endothelium dependent relaxations in the artery than in the vein. Endothelium removal and pretreatment with nitro-arginine abolished the relaxations completely in saphenous vein but not in gastroepiploic artery, depending on the relaxing agent used. On the other hand, both graft materials showed nearly equal sensitivity to endothelin-1 (EC50 values; 3.5 x 10(-9) M in the vein versus 6.4 x 10(-9) M in the artery, p = NS) which was not affected by endothelium removal. CONCLUSIONS: Gastroepiploic artery exhibited more pronounced relaxation and a different response profile to endogenous vasoactive substances than saphenous vein. The demonstration of higher capacity of the artery to release vasoactive substances in response to various endogenous agents shows that gastroepiploic artery may have a better long term patency rate than saphenous vein.