The Effect of Circadian Melatonin Levels on Inflammation and Neurocognitive Functions Following Coronary Bypass Surgery.

PURPOSE: In this study, the relationship between the plasma levels of melatonin and intercellular adhesion molecule-1 (ICAM-1), which plays role in several intercellular interactions including inflammatory and immune responses, and early neurocognitive functions associated with ischaemia-reperfusion injury during open heart surgery is examined. METHODS: Forty patients who were to undergo elective coronary artery bypass grafting (CABG) were divided into two groups, those who underwent their operations at 8 AM (group I; n = 20) and those who underwent their operations at 1 PM (group II; n = 20). Blood samples were collected prior to surgery (S1), when the aortic cross clamp was removed (S2) and 4 (S3) and 24 h after the surgery (S4). Neuropsychiatric assessment was conducted one day before and seven days after surgery. RESULTS: Melatonin levels measured during and after surgery were also significantly higher in Group 1. ICAM-1 levels were significantly lower in Group 1 at S2 and S3. Significant deterioration was observed in postoperative neurocognitive function compared with preoperative functions in Group 2 more than Group 1. CONCLUSION: We hypothesise that the greater preservation of neurocognitive functions in the morning patients is associated with elevated melatonin levels, which reduce the damage from ischaemia-reperfusion injury.

Recurrent Prosthetic Mitral Valve Dehiscence due to Infective Endocarditis: Discussion of Possible Causes.

Prosthetic valves are being widely used in the treatment of heart valve disease. Prosthetic valve endocarditis (PVE) is one of the most catastrophic complications seen in these patients. In particular, prosthetic valve dehiscence can lead to acute decompensation, pulmonary edema, and cardiogenic shock. Here, we discuss the medical management of late PVE in a patient with a prior history of late and redo early PVE and recurrent dehiscence. According to the present case, we can summarize the learning points as follows. A prior history of infective endocarditis increases the risk of relapse or recurrence, and these patients should be evaluated very cautiously to prevent late complications. Adequate debridement of infected material is of paramount importance to prevent relapse. A history of dehiscence is associated with increased risk of relapse and recurrent dehiscence.

Short-term and mid-term results with the Sorin Freedom Solo aortic valve.

BACKGROUND AND AIM OF THE STUDY: The study aim was to present the short- and mid-term results for patients who underwent aortic valve replacement (AVR) with the Sorin Freedom Solo third-generation stentless prosthetic valve. METHODS: AVR with a Sorin Freedom Solo valve was performed in 14 patients between March 2006 and March 2011. Patients aged > or = 60 years (male:female ratio 6:8; mean age 73.28 +/- 5.42 years) who required AVR with the Sorin Freedom Solo valve according to the surgeon's choice were included in the study. The valvular prosthesis was implanted in the supra-annular position, using a single suture line. RESULTS: Eight patients underwent an isolated AVR; combined interventions were carried out in the other patients due to concomitant cardiac disease. One patient died during the immediate perioperative period, and two more during the follow up, from non-cardiac causes. The mean maximum transvalvular gradient of patients with aortic stenosis was 88.1 +/- 20.2 mmHg, and this fell to 26.4 +/- 7.6 mmHg during the early postoperative period. The mean gradient at one year of follow up was further decreased to 19.4 +/- 5.3 mmHg. The left ventricular end-diastolic and end-systolic diameters were also significantly reduced, from 4.8 +/- 0.9 to 4.3 +/- 0.6 cm and from 3.2 +/- 0.6 to 2.8 +/- 5.3 cm, respectively. The average left ventricular ejection fraction was 60.2 +/- 4.9% preoperatively, and 63.2 +/- 2.1% at one year after surgery (p = NS). No paravalvular leakage, endocarditis, prosthesis failure or neurologic events were reported among patients. CONCLUSION: The Sorin Freedom Solo stentless valve has provided good early and intermediate-term results. Implantation of the prosthesis is straightforward, with low rates of morbidity and mortality. However, these data require further support from larger patient series and long-term follow up.

Lateral cavoatriotomy for partial anomalous pulmonary venous connection to the superior vena cava.

PURPOSE: Surgical correction of the partial anomalous pulmonary venous connection (PAPVC) draining into the superior vena cava (SVC) has been associated with sinus node dysfunction and venous return obstruction, postoperatively. We present the results of our lateral cavoatriotomy approach with little modifications to avoid injury to the sinus node and its artery. METHODS: 32 patients who underwent surgical repair of PAPVC to SVC with modified lateral cavoatriotomy in our clinic between January 2003 and January 2009 were evaluated retrospectively. RESULTS: Median age was 6 years (2-32 years). The mean follow-up time was 65.8 ± 23.7 months (36-111 months). There were no early or late deaths. No patients required reoperation. New onset of arrhythmia had developed in two patients and resolved before hospital discharge. Stenosis of the SVC in one patient had developed 11 months after the operation and was treated with balloon angioplasty, successfully. No sinus node dysfunction or venous return obstruction was detected in their last follow-up. CONCLUSION: Cavoatrial incision for repair of PAPVC to SVC may become a safer surgical technique with some modifications.

Isolated ruptured inter-atrial septal cystic echinococcosis during pregnancy.

Herein, we present a case of asymptomatic isolated cardiac cystic echinococcosis localized entirely to the inter-atrial septum in a pregnant woman. The patient underwent successful surgery. Cardiac cystic echinococcosis is rarely seen in pregnancy. A high index of suspicion is necessary for the diagnosis of a cardiac cyst hydatid. The treatment of cardiac cyst hydatid is surgical and should not be delayed during pregnancy. Early surgery might prevent septic embolization and cardiac life-threatening complications and save the lives of both mother and baby as in the present case.

Contribution of giant aneurysm of a membranous ventricular septal defect to right ventricular outflow tract obstruction.

Perimembranous defects are the most common types of ventricular septal defects (VSDs). In many cases, an aneurysm accompanies this defect. The aneurysm can have advantageous consequences on defect hemodynamics. However, it also has numerous complications that are frequently encountered in clinical practice. In this case, we describe a patient with a membranous VSD with giant aneurysm formation contributing to subpulmonic severe obstruction.

Urgent surgical management for embolized occluder devices in childhood: single center experience.

BACKGROUND: In this study, we sought to analyze our experience in urgent surgical management for embolized cardiac septal and ductal occluder devices resulting from trans-catheter closure of atrial septal defect, ventricular septal defect and patent ductus arteriosus in childhood patient group. METHODS: We retrospectively reviewed 9 patients (aged 2-15 years) who underwent urgent surgery due to cardiac septal and ductal occluder embolization between January 2007 and December 2010. Congenital defects were atrial septal defect (n = 6), ventricular septal defect (n = 1), and patent ductus arteriosus (n = 2). Risk factors for device embolization and urgent surgical management techniques for embolized device removal were discussed. RESULTS: Removal of embolized devices in all cases and repair of damaged tricuspid valve in 2 patients were performed. Inevitably, all congenital defects were closed or ligated up to the primary defect. Total circulator arrest necessitated in 1 patient with ascending aortic device embolization. All operations were completed successfully and no hospital mortality or morbidity was encountered. CONCLUSIONS: Although closure of left to right shunting defects by percutaneous occluder devices has a lot of advantages, device embolization is still a major complication. If embolized device retrieval fails with percutaneous intervention attempts, surgical management is the only method to remove embolized devices. In this circumstance, to provide an uneventful perioperative course, urgent management strategies should be well planned.

Treatment outcomes of postoperative mediastinitis in cardiac surgery; negative pressure wound therapy versus conventional treatment.

BACKGROUND: The aim of the present study is to compare negative pressure wound therapy versus conventional treatment outcomes at postoperative mediastinitis after cardiac surgery. METHODS: Between January 2000 and December 2011, after 9972 sternotomies, postoperative mediastinitis was diagnosed in 90 patients. The treatment modalities divided the patients into two groups: group 1 patients (n = 47) were initially treated with the negative pressure wound therapy and group 2 patients (n = 43) were underwent conventional treatment protocols. The outcomes were investigated with Kaplan-Meier method, log-rank test, Student's test and Fisher's exact test. RESULTS: The 90-days mortality was found significantly lower in the negative pressure wound group than in the conventionally treated group. Overall survival was significantly better in the negative pressure wound group than in the conventionally treated group. CONCLUSION: Negative pressure wound therapy is safe and reliable option in mediastinitis after cardiac surgery, with excellent survival and low failure rate when compared with conventional treatments.

Cardiovasular changes after placement of a classic endotracheal tube, double-lumen tube, and Laryngeal Mask Airway.

STUDY OBJECTIVE: To compare hemodynamic responses, P wave dispersion (Pd), and QT dispersion (QTd) after placement of a classic endotracheal tube (ETT), double-lumen tube (DLT), or Laryngeal Mask Airway (LMA). DESIGN: Prospective study. SETTING: Outpatient surgery center. PATIENTS: 75 adult, ASA physical status 1 and 2 patients undergoing cystoscopy and thoracoscopic surgery. INTERVENTIONS: Patients were randomized to undergo placement of an ETT (Group T; n = 25), DLT (Group D; n = 25), or LMA (Group L; n = 25). Anesthesia was induced by etomidate 0.3 mg/kg and fentanyl 1.0 µg/kg, and maintained with nitrous oxide, oxygen, 2% to 3% sevoflurane, and rocuronium 0.5 mg/kg. MEASUREMENTS: Mean arterial pressure (MAP) and heart rate (HR) were recorded immediately before intubation and after intubation at one, 3, 5, 10,15, 20, 25, and 30 minutes after intubation/airway insertion. RESULTS: QT dispersion after tube placement was significantly higher than before tube placement in Group D (P = 0.0001) and Group L (P = 0.03). Mean arterial pressure and HR in Group T were significantly higher than in Group L at the first minute after tube placement (P = 0.02). Heart rate and MAP at baseline were significantly higher than the other measurement times in Groups T and D (P < 0.01). CONCLUSIONS: The LMA caused no change in Pd, HR, or MAP values during or after airway placement, but caused QTd after airway insertion. The ETT caused a sudden increase at the first minute after tube placement, without any Pd or QTd. In addition, DLT caused QTd without any serious change in hemodynamics.

Pericardial monocusp reconstruction for pulmonary valve vegetation secondary to patent ductus arteriosus.

A case of pulmonary valve endocarditis in a patient with a ductus arteriosus (PDA) is reported. The PDA was ligated, the septal leaflet of the pulmonary valve was excised, and a pericardial monocusp reconstruction was performed.

Leiomyosarcoma protruding into the left ventricle during diastole: report of a case.

Cardiac leiomyosarcoma is a rare tumor with poor survival prospects. Surgery prolongs survival, but the tumor often recurs early after surgery. The diagnosis is often made by transthoracic echocardiography. Magnetic resonance imaging and computed tomography are required to characterize the location and extent of cardiac masses. In this report, we present a patient with a leiomyosarcoma that was resected completely. The tumor was located in the left atrium, mimicked a myxoma, and protruded into the left ventricle during diastole.

Ultrasound-guided infraclavicular brachial plexus block enhances postoperative blood flow in arteriovenous fistulas.

OBJECTIVE: Brachial plexus block offers several advantages when creating vascular access for hemodialysis. However, no controlled studies have directly evaluated arteriovenous fistula (AVF) blood flow in patients anesthetized by this method. We compared the effects of ultrasound-guided, infraclavicular brachial plexus block and local infiltration anesthesia on blood flow in the radial artery and AVF during the early and late postoperative periods. METHODS: Sixty patients were randomly assigned to an experimental group, which received infraclavicular brachial plexus block (IB), or to a control (C) group that received local infiltration anesthesia. Blood flow in the distal radial artery was measured before and after IB or infiltration anesthesia. AVF flow during the early and late postoperative period was evaluated using duplex ultrasound imaging. The rates of primary fistula failure were also compared. RESULTS: After anesthesia, preoperative radial arterial flow was 56 ± 8.6 mL/min in group IB vs 40.7 ± 6.11 mL/min in group C (P < .0001). Blood flow in the fistula, measured in mL/min at 3 hours, 7 days, and 8 weeks postoperatively, was also greater in group 1B vs group C, respectively, at 69.6 ± 7.9 vs 44.8 ± 13.8 (P < .001), 210.6 ± 30.9 vs 129 ± 36.1 (P < .001), and 680.6 ± 96.7 vs 405.3 ± 76.2 (P < 0.001). CONCLUSION: When used for AVF access surgery, infraclavicular brachial plexus block provides higher blood flow in the radial artery and AVF than is achieved with infiltration anesthesia.

P-wave dispersion between transcatheter and surgical closure of secundum-type atrial septal defect in childhood.

Patients with atrial septal defect have an increased risk for atrial fibrillation. Increased P-wave dispersion predicts the development of atrial fibrillation. The aim of this study was to determine difference in P dispersion between transcatheter closure with Amplatzer septal occluder and surgical closure in childhood. A total of 68 children (the mean age was 7.2 plus or minus 3.3 years; the mean secundum atrial septal defects diameter was 17.3 plus or minus 5.4 millimetres) were evaluated in this study. Transcatheter closure was attempted in 41 children with secundum atrial septal defects, and the defect in 27 patients was closed by surgical techniques. P maximum, P minimum and P dispersion were measured by the 12-lead surface electrocardiography. P maximum, P minimum and P dispersion were found to be similar in patients with pre- and post-procedure (98.0 plus or minus 19.3 versus 95.1 plus or minus 23.0 milliseconds; 68.0 plus or minus 20.8 versus 67.6 plus or minus 24.3 milliseconds, 29.9 plus or minus 11.0 versus 27.1 plus or minus 12.1 milliseconds, respectively). There was no statistical significance in the comparison of P dispersion between the two groups. But in the surgical group, P-wave dispersion was decreased more significantly compared with baseline values (p-value equal to 0.03). In conclusion, there is no P dispersion between transcatheter closure with Amplatzer septal occluder and surgical closure of secundum atrial septal defect.

Does the circadian rhythm of melatonin affect ischemia-reperfusion injury after coronary artery bypass grafting?

BACKGROUND: Melatonin is a potent scavenger of free radicals and an antioxidant. We studied the relationship between the protective effect of melatonin against ischemia-reperfusion injury (IRI) during cardiopulmonary bypass, the plasma level of melatonin, and the time of surgery. METHODS: Forty patients who were to undergo elective coronary artery bypass grafting (CABG) were divided into 2 groups, those who underwent their operations at 8 AM (group I; n = 20) and those who underwent their operations at 1 PM (group II; n = 20). The operations were carried out by the same surgical team and with the same standard surgical technique. Blood samples were collected before the operation (T1), when the aortic cross-clamp was removed (T2), and at 4 hours (T3) and 24 hours (T4) after the operation. RESULTS: Preoperative plasma levels of melatonin were substantially higher in group I than in group II. Intraoperative and postoperative melatonin levels were also significantly higher in patients who underwent their operations in the morning. The 2 groups had similar preoperative levels of intercellular adhesion molecule 1 and interleukin 8; however, intraoperative and postoperative values were lower in group I for all samples. This difference was statistically significant for both markers. Plasma levels of lactate dehydrogenase were significantly lower in group I. The 2 groups had similar aortic cross-clamp and cardiopulmonary bypass times. Preoperative and postoperative troponin I levels were lower in group I than in group II, but these differences were not statistically significant. The 2 groups showed no significant differences in plasma creatine kinase MB levels for either preoperative or postoperative measurements. CONCLUSION: High plasma levels of melatonin may be directly related to low levels of IRI markers. Melatonin may have a protective effect against IRI in CABG. This effect seems to be directly correlated with the plasma levels of melatonin and inversely related with light. If melatonin protects myocardium from IRI, additional studies may be planned for the preoperative use of melatonin in patients with coronary artery disease to improve myocardial protection.

[The role of multislice tomography to prevent postoperative strokes related with atherosclerotic plaques in the ascending aorta after coronary artery bypass]. / Koroner baypas operasyonu sonrasi assandan aorttaki aterosklerotik plaklara bagli inmenin önlenmesinde çok kesitli tomografinin rolü

OBJECTIVE: Atheromatous plaques in the ascending aorta are major risk factors for strokes caused by macroembolization after coronary artery surgery. Detection of plaque formations and changes in the surgical strategy are very important. This study was planned to compare value direct palpation and multislice computerized tomography to establish aortic plaques and to establish clinical predictors of aortic calcification. METHODS: Fifty-four patients who underwent coronary bypass surgery were included in this prospective and diagnostic study. Proximal portion of each patient's aorta was evaluated with multislice computerized tomography and was compared with direct palpation. The efficacy of intraoperative palpation to predict calcifications was studied with ROC analysis and the predictors of aortic plaque formation were analyzed using logistic regression analysis. RESULTS: Atheromatous plaques were detected with palpation in four patients (7.4%), and with multislice tomography in six patients (11.1%). The aortic instrumentation was changed in two patients (3.7%) and strategy was changed in one patient 1.8%). According to the ROC analysis, when multislice computerized tomography was taken as the reference, intraoperative direct palpation was 67% sensitive and 100% specific to predict aortic plaques. Logistic regression analysis of the risk factors showed that the older age was the only significant risk factor (OR-1.3, 95% CI -1.114-1.568, p=0.001) for plaque formation in the aorta. Neither stroke nor other neurological disorders have been observed during the study. CONCLUSIONS: It can be stated that multislice computerized tomography is more effective to show aortic plaques, but it is not sufficient. Multislice tomography may give additional information about the ascending aorta and the opportunity to visualize the aortic arch. It can be preferred in patients with aortic aneurysm or dissection.

Risk factors for posterior ventricular rupture after mitral valve replacement: results of 2560 patients.

OBJECTIVE: Posterior ventricular rupture is a rare and fatal complication of mitral valve surgery. This study is designed to define the risk factors for left ventricular rupture after mitral valve replacement and, especially, to find out if posterior leaflet preservation is protective for posterior ventricular rupture. METHODS: Between January 1996 and March 2007, 2560 patients underwent mitral valve replacement operation in our hospital. Risk factors for posterior ventricular rupture were studied with chi(2) and logistic regression analysis. RESULTS: The surgery was complicated with posterior ventricular rupture in 23 (0.8%) of 2560 patients. Nineteen patients (82.6%) were female, four patients (17.4%) were male. Mean age of the patients in this group was 60+/-10. Mortality rate of the patients with posterior ventricular rupture was 86% (20 patients). Twelve patients with posterior ventricular rupture were at the age of 60 and older. Age of 60 and above was found as a highly significant risk factor for posterior ventricular rupture (OR 4.53, 95% CI 1.98-10.38, p<0.001). Posterior leaflet was preserved in 513 patients (20%) and posterior ventricular rupture did not occur in these patients. Resection of posterior leaflet was also found as a highly significant risk factor (p=0.008) for posterior ventricular rupture. Reoperation was performed in 372 patients and posterior ventricular rupture occurred in 7 of them. Reoperation was also found as a significant risk factor (OR 2.563, 95% CI 1.03-6.34, p=0.042) for posterior ventricular rupture. CONCLUSIONS: Extreme annular traction and aggressive decalcification should be avoided during mitral valve resection. Posterior leaflet of the mitral valve should be preserved, especially in the older age group to prevent posterior ventricular rupture.

Primary cardiac rhabdomyosarcoma of the right atrium: case report.

Rhabdomyosarcoma is a rare malignant tumor of the heart that accounts for 20% of all primary malignant neoplasms of the heart. Symptoms vary in accordance with the location of the mass; unfortunately, by the time the patient becomes symptomatic, the tumor has already metastasized to other organs. Diagnosis is frequently obtained via transthoracic or transesophageal echocardiography and nuclear magnetic resonance imaging. Surgery is indicated for malignant cardiac neoplasms to relieve cardiac symptoms and to prolong patient survival. Subsequent postoperative chemotherapy or radiotherapy is necessary, and the long-term prognosis is poor. We present a case of a primary cardiac rhabdomyosarcoma that arose from the lateral wall of the right atrium and required implantation of a permanent cardiac pacemaker after surgery.