Use of multidetector computed tomography angiography of upper limb circulation in patients undergoing coronary artery bypass grafting surgery.

OBJECTIVE: This study aimed to evaluate the bilateral forehand circulation using a 64-channel multidetector computed tomography (MDCT) as a noninvasive method to define criteria for an upper extremity arterial anatomy and pathology prior to the use of arterial conduits. MATERIALS AND METHODS: Fifty-five patients with coronary artery disease who underwent total arterial coronary artery bypass grafting (CABG) were randomly selected for this prospective study. MDCT angiography was performed for 110 examinations of forearm and hand arterial anatomy. Prior to MDCT, Allen tests were performed in all patients with a normal result, except four. Thirteen patients had diabetes mellitus (DM), 8 had peripheral artery occlusive disease, and 19 had a history of smoking. RESULTS: All arteries, including axillary, ulnar artery (UA) and radial artery (RA), were clearly visualized in all patients. Upper extremity anatomical and pathological results were examined in 16 patients (29.1%). Severely calcified RA and/or UA were found in 6 patients who had a moderate renal failure. Nearly total occlusion of the RA was detected in another two patients. Focal intimal RA calcification was recorded in 1 female and 3 male patients. Ten patients who had severe calcification or intimal sclerosis of the upper extremity arteries had DM. The remaining patients had normal forehand arterial circulation. A persistent median artery with the absence of radial and ulnar arteries and a high bifurcation of RA from the brachial artery was detected as an anatomic variation in seven patients (12.7%). CONCLUSIONS: The major advantages of MDCT angiography are its non-invasiveness and the ability to detect calcific subadventitial plaques, which are difficult to diagnose using conventional angiography. MDCT may be used as a safe and non-invasive method to assess RA and UA prior to harvesting the upper limb artery. Preoperative imaging of forehand arteries is a means to avoid unnecessary forearm exploration or the use of an unsuitable arterial conduit in CABG operations, especially in patients with DM and moderate renal impairment.

Local use of ankaferd blood clotter in emergent beating heart coronary artery bypass grafting.

BACKGROUND: Severe beeding which requiring massive blood transfusion after emergent beating heart surgery is shown to be 1-3%. Therefore, complications and side effects of transfusion can be seen. The aim of this study was to investigate the effectiveness of Ankaferd blood clotter (ABC) as a new topical herbal blood clotter to decrease mediastinal bleeding in emergent beating heart CABG patients who medicated with clopidogrel and acetyl salisilic acite (ASA) prior to CABG surgery. MATERIALS AND METHODS: 25 CABG patients received a high dose clopidogrel (600 mgr) and 300 mgr ASA have been included into the study (ABC group). 25 patients have also been included into the study for comparison (placebo group, PG). After the administration of protamine sulphate, a 10 ml of ABC solution has been sprayed to the surgical area including mediastinum and epicardial sac. We compared mediastinal drenaige, reoperation due to tamponade, and required blood and blood products in both groups. RESULTS: The mean amount of bleeding after operation was 230 ml in ABC group, and 490 ml in CG (P=0.001). In ICU, bleeding in ABC group and CG was 410ml and 680ml, respectively (P=0.0022). The mean total bleeding from mediastinum was 530±280 mL and 990±440 mL In ABC and CG group, respectively (P=0.001). The amount of autotransfusion was as follows: 175 mL in ABC group, and 290 mL in CG (P=0.002). No patient needed the surgical revision in ABC group, but four patients (16%) from CG group because of cardiac tamponade. Seventeen patients from CG required blood transfusion due to low hematocrite level postoperatively. In CG, the mean hematocrite level was 17±2,3. Transfusion of fresh frozen plasma and platelets in ABC group and CG were as follows: 0.2 and 0 in ABC group, and 0.3and 0.4 in CG. CONCLUSION: Our study showed that the local use of 10 mL ABC reduces bleeding significantly. Therefore, transfusion requirements of PRBC, platelets, and total blood units in patients on clopidogrel and ASA undergoing emergent beating heart CABG. To provide cardiac tamponade because of excessive mediastinal bleeding and requirement of blood transfusion after emergent CABG patients who previously administered clopidogrel and ASA, we propose local use of ABC solution as a potent coagulant agent.

Protective role of intracoronary shunt in off-pump coronary bypass operations.

OBJECTIVE: To investigate if there are any advantages in using intracoronary shunts compared to shuntless operations, in the context of whether it has a protective role for the myocardia. METHODS: This prospective study, included 100 patients who underwent off-pump coronary bypass surgery at 2 different cardiovascular surgery departments, namely, the Social Security Ankara Ihtisas Hospital, and Hacettepe University Hospital, Turkey, between September 2002 and July 2006. Patients were divided into 2 groups. In group 1 n=50 off-pump coronary bypass operations were performed with intracoronary shunts. In group 2 n=50 shunts were not used during off-pump. Serum creatine kinase, myoglobin, and troponin were studied. RESULTS: There were significant increases in serum creatine kinase levels in group 2 at postoperative 6th, 12th, and 24th hours. In group 2, the increase of myoglobin was statistically significant at only the postoperative 24th hour. Troponin levels were significantly higher in group 2 at postoperative 6th, 12th, and 24th hours. CONCLUSION: There are some questions regarding myocardial protection while maintaining a bloodless secure surgical field in off-pump coronary surgery. However, use of intracoronary shunts provides distal coronary flow, and reduces the risk of myocardial ischemia, while maintaining a comfortable blood free anastomosis area.

The role of surface ECG and transthoracic echocardiography for predicting postoperative atrial fibrillation after coronary artery bypass surgery.

OBJECTIVE: To evaluate the roles of surface electrocardiogram (ECG) and transthoracic echocardiography (ECHO) for prediction of atrial fibrillation (AF) after coronary artery bypass grafting (CABG). METHODS: This study was conducted from 2002-2004 at the Cardiovascular Department of Hacettepe University, Ankara, Turkey. Seventy consecutive patients were enrolled in this study that underwent elective CABG. A 12-lead ECG was recorded one day before cardiac surgery and was repeated during the 5 days after CABG. P-wave dispersion (PWD) was defined as the difference between maximum and minimum P-wave duration. Differences in P-wave duration were compared between the pre- and postoperative 12-lead ECG measurements. RESULTS: Postoperative AF developed in 17 (24%) cases of 70 patients. The PWD was found to be significantly higher in patients with AF preoperatively (60+/-19 versus 47+/-13, p=0.003), postoperative first day (56+/-12 versus 44+/-11, p<0.002) and fifth day (51+/-29 versus 41+/-11, p<0.001). Patients with AF were significantly older, the mean age of the AF group was (68+/-7) years and of the sinus rhythm (SR) group was (59+/-10 years) (p<0.001). The AF group had left ventricular systolic dysfunction (56+/-13% versus 56+/-8%, p=0.042, preoperatively; 49+/-8% versus 60+/-10%, p=0.001, postoperatively) and a larger left atrium (46+/-5 versus 39+/-5 mm, p<0.001, preoperatively and 44+/-7 versus 39+/-5 mm, p=0.046, postoperatively) than the SR group. CONCLUSION: This prospective study demonstrated that PWD on surface ECG and additional echocardiographic parameters are simple and reliable indexes to predict the development of AF after CABG.