Exploring at the molecular level the effects of blood and blood-insulin cardioplegias used during open-heart surgeries on myocardial prevention.

AIM: The aim of this study was to measure the changes in the levels of soluble adhesion molecules involved in acute inflammation during ischemia-reperfusion in adults who underwent open-heart surgery using blood and blood-insulin cardioplegia and to examine the differences in tissue damage at the molecular level as a consequence of insulin's effect on myocardial energy metabolism. METHODS: Non diabetic 36 patients were enrolled. Blood cardioplegia was used at all cases; insulin and glucose were added at the study group. Blood samples were taken from the coronary sinus and the radial artery before cross-clamp (T1), at 1st (T2) and 30th(T3) minutes after reperfusion. Soluble intercellular adhesion molecules-1 (sICAM-1), soluble vascular adhesion molecules-1 (sVCAM-1), soluble platelet/endothelial cells adhesion marker-1 (sPECAM-1) and serum lactate levels were measured in these samples. Cardiac enzymes (CK-MB, troponin, and myoglobin) were measured at postoperative 1th, 8th and 16th hours. The total duration of mechanical ventilatory support during postoperative period, and the number of days in the intensive care unit and hospital were recorded. RESULTS: No significant differences were observed in sVCAM-1 levels in blood taken from the radial artery at T1, T2 and T3 in either group. There were significant increases between T1 and T3 and between T2 and T3 in samples obtained form the coronary sinus (P=0.000 and P=0.003, respectively). Significant increases in sPECAM-1 in samples obtained from both sites between T2 and T3 in both groups (P=0.000) were observed. These differences were similar in both groups. Troponin levels at 8th and 16th hours in the blood-insulin cardioplegia group were higher than the blood cardioplegia group (P=0.003 and P=0.032, respectively). CONCLUSION: Supplementation of blood cardioplegia with insulin did not yield a significant improvement in adhesion molecules. Therefore, superiority of one cardioplegia over the other in delivering myocardial protection during open-heart surgery has not been shown.

Insulin-blood cardioplegia decreases matrix metalloproteinase activity in ischaemia-reperfusion injury during coronary artery bypass surgery.

Reperfusion of myocardium during coronary bypass activates matrix metalloproteinases (MMPs) with changes occurring in the levels of tissue inhibitors of metalloproteinases (TIMPs) in the myocardium. This study investigated the effects of insulin-blood cardioplegia on MMP activity and TIMP levels during reperfusion. Non-diabetic patients undergoing coronary artery bypass graft with cardiopulmonary bypass were randomized into a control group (n = 12) or an insulin group (n = 12). Blood cardioplegia was used for both groups; insulin and glucose were added to the insulin group. Blood samples were obtained from the coronary sinus just before aortic cross clamping and after 1 and 30 min of reperfusion. Plasma proenzyme MMPs (proMMP-2 and -9) and TIMPs (TIMP-1 and TIMP-2) levels were measured. There were no differences between groups for MMP-2 and TIMP-2 levels. However, insulin diminished proMMP-9 activation, although some still occurred. TIMP-1 consumption lessened during reperfusion which, we conclude, was as a result of the diminished MMP activation. This is the first open heart surgery study in which diminished MMP activation was achieved via a metabolic change.

Aortic ruptured following lung resection in invasive aspergillosis.

Invasive pulmonary aspergillosis, although rare in the general population, can prove to be an important cause of morbidity and mortality in immunosuppressed patients. In this paper we represent a case of aortic rupture for a fungal invasion of the aorta after a pulmonary resection procedure. Although a few cases are documented in the literature, we report our experience to make our colleagues aware of this complication.

A new closure technique for limited thoracotomy where the ribs are spread minimally.

An alternative closure technique for limited thoracotomy incisions is described below. This technique consists of fixing the intercostal muscles with horizontal mattress sutures. Also the described technique can be applied where the ribs are spread minimally in such limited thoracotomy incisions.

The role of autologous blood injection on postoperative air leak at lung resections.

BACKGROUND: The effects of autologous blood injection beneath the stapling lines on postoperative air leak after lung resections, especially in emphysematous lungs, were prospectively investigated. METHODS: The study was carried out on 16 randomized patients. The mean age of the study group was 58 and the mean forced expiratory volume at one second (FEV1) at the spirometry was 2.05 L. In the control group, the mean age was 60 and the mean FEV1 was 1.97 L. All 16 cases were males and had a history of smoking. In the study group, 10-20 ml of autologous venous blood was drawn by the anesthesist and transferred to the operation team. The blood was gently injected underneath the staple line and ultimately 1 cm thickened layer of the lung was obtained. In the control group only staplers were applied. RESULTS: There was no air leak at the end of the operation at the study group, whereas additional sutures which were pledgetted with Gore-tex patches were needed at four cases at the control group. There were minimal air leaks at three cases at the control group at the postoperative period, while there was no postoperative air leak problem at the study group. Thorax tubes were removed at the 3rd and the 3.9th days at the study and the control groups, respectively. CONCLUSIONS: We believe this simple and cheap method could be used at least in some instances where additional staple reinforcement would be necessary. It may also be remembered when air leaks are encountered at suture holes after suturing the lung.

Cost-effectiveness of minimally invasive-intervention in aortofemoral revascularization.

Minimally invasive surgical procedures have become popular recently because they offer several advantages over conventional operative techniques. A person undergoing a minimally invasive procedure usually experiences less pain, is discharged earlier from hospital, returns to work sooner and has a less obtrusive post-operative scar. Excluding highly technical techniques (e.g. laparoscopic surgery), operations performed using mini-laparotomy are usually more cost-effective than conventional procedures, largely because they are less expensive to perform. Our paper investigates cost-effectiveness and other parameters relating to minimally invasive aortofemoral revascularization procedures performed at our clinic. We compared 20 similar cases, half where revascularization was undertaken using mini-laparotomy and half where conventional laparotomy was selected. From our findings we conclude that mini-laparotomy is safe and reliable for aortobifemoral bypass procedures and has several advantages over traditional techniques; namely, shorter operating time, earlier resumption of intestinal function, shorter duration of in-patient stay and reduced costs.

Transthoracic colour Doppler ultrasonography in the evaluation of internal thoracic artery bypass graft patency.

The internal thoracic artery (ITA) is the most important conduit for coronary artery bypass grafting. The quality of the anastomosis joining the ITA to the left anterior descending coronary artery has a major impact on left ventricular perfusion. The rapid detection of flow disturbances due to sub-optimal anastomosis is, therefore, of great prognostic significance. In this study, 47 coronary bypass patients were examined using colour Doppler ultrasonography peri-operatively and 4-6 months post-operatively. Findings were correlated with clinical observations and a treadmill exercise test. The pre-operative ITA flow pattern was normally triphasic, but changed post-operatively to simulate the normal biphasic flow pattern of left anterior descending coronary artery. A 35-case-control group was used to compare pre-operative ITA flow characteristics. The authors conclude that Doppler parameters, clinical findings and the treadmill test can be used in combination for the routine evaluation of graft patency, and to select cases that require more invasive coronary angiography.

Ligation of patent ductus arterious by the method of video-assisted thoracoscopic surgery and our other VATS experiences.

In April and May 1996, two cases of PDA ligation were performed firstly in Turkey by the method of video assisted thoracoscopic surgery (VATS) in Dokuz Eylül Medical Faculty, Thoracic and Cardiovascular Surgery Department. There was not any complication in these patients in the postoperative period and they were discharged on the second day in symptom-free condition by the detection of closed ductus in their echocardiographic examination. Between February 1993 and October 1996, a total of 46 patients have undergone interventional application by VATS. While in six of these patients the procedure could not be manipulated because of massive pleural fibrosis, there was no mortality or morbidity among the patients, and they were discharged on average on the second day. The ratio of complications, such as bleeding, air leak, arrhythmia and empyema are so low in these operations, and hospital stay, with return to work time are shorter than with the open technique.

Lung-volume reduction in parallel with coronary heart surgery: a case report.

For patients with severe disabling emphysema, lung-volume reduction surgery has recently been introduced as an alternative to transplantation. Performing parenchyma resection from appropriate areas can improve pulmonary functions in selected patients having severe emphysema with a flattened diaphragm. We report the case of a patient, who urgently needed coronary revascularization and was otherwise inoperable because of severe chronic obstructive pulmonary disease (COPD). We carried out lung-volume reduction surgery at the same time as the coronary bypass.

Relationship between high serum digoxin levels and toxicity.

A retrospective study of 1,269 patients on digoxin was done to determine the relationship between serum digoxin levels of 3.0 ng/ml or higher and clinical toxicity. Of 1,269 patients, 58 (4.6%) had digoxin serum levels of 3.0 ng/ml or higher. Clinical evidence of digoxin toxicity was present in only 11 of these patients and premature blood sampling accounted for the high levels in 10 other nontoxic patients. None of the patients with clinical toxicity died. The other 37 patients tolerated the high digoxin levels without exhibiting toxic effect. Low cardiac output, concomitant use of other drugs, and impaired renal function increased the serum digoxin levels in patients with and without clinical toxicity. Appropriate therapeutic digoxin level monitoring and confirmatory laboratory-clinical relationship may have important influences on these results. Additional work on further definition of "toxic" digoxin levels needs to be performed.

A comparison of digoxin concentration--time curves before and after open-heart surgery.

The effects of open heart surgery on serum digoxin concentration--time curves were investigated in 10 cardiac patients receiving 0.25 mg/day digoxin. Blood samples were obtained from the patients immediately before and 1, 2, 3, 5, 8, 16 and 24 h after digoxin administration, both before open-heart surgery and 7 days after surgery. Serum digoxin concentrations, determined by fluorescence polarization immuno-assay, significantly (P < 0.05) increased after surgery, as did the maximum serum concentrations and the areas under the concentration-time curves. After surgery there was a significant increase in the serum gamma-glutamyl transferase concentration and a significant reduction in the total protein concentration. A reduction of digoxin dose may be appropriate for patients who have undergone open-heart surgery.