Incidence of anti-heparin/platelet factor 4 antibodies and heparin-induced thrombocytopenia in medical patients.

OBJECTIVE: Heparin-induced thrombocytopenia (HIT) is a life threatening complication of heparin therapy, causing thrombosis. The aim of our study was to find out the frequencies of HIT antibody seroconversion and clinical HIT in Turkish medical patients on different forms of heparins. METHODS: Our study included 61 patients who were on unfractionated heparin (UFH) (n: 37) and low molecular weight heparin (LMWH) (n: 24) therapies. The frequency of HIT antibody formation was determined by means of antigenic (ELISA), and functional assays (serotonin release assay-SRA). RESULTS: The seroconversion rates in UFH and LMWH groups were found to be 18.9% and 4.1% (ELISA), and 8.1% and 4.1% (SRA), respectively. One patient (2.1%) on UFH therapy developed deep vein thrombosis. No thromboembolic event was observed in patients taking LMWH. CONCLUSION: Seroconversion rates by means of antigenic and functional assays and clinical HIT were more common in patients on UFH than patients on LMWH therapy.

Incidence of antiheparin-platelet factor 4 antibodies and heparin-induced thrombocytopenia in Turkish patients undergoing cardiac surgery.

The frequency of antiheparin-platelet factor 4 antibodies by means of antigenic and functional assays ((14) C-serotonin release assay and citrated plasma platelet aggregation) was determined in 115 Turkish patients undergoing cardiac surgery. Blood samples were taken immediately before surgery and on days 5 and 10 +/- 2. Platelet counts were recorded and thrombotic events were determined by clinical methods. Antibody generation measured by enzyme-linked immunosorbent assay before surgery (n = 44) and on days 5 (n = 44) and 10 (n = 115) was 15.9%, 34.1%, and 65.2%, respectively. Positive samples from functional assays were 4.4% on day 0 and 7.0% on day 10. All positive samples had been negative on day 0. A high frequency of antiheparin-platelet factor 4 antibody generation and a low frequency of clinical heparin-induced thrombocytopenia were determined in these patients. These results obtained for Turkish patients are similar to those of other studies of heparin-induced thrombocytopenia.

Analysis of C-reactive protein and biochemical parameters in pericardial fluid.

This study was designed to examine the relationship between pericardial fluid and plasma CRP levels, and to alterations in other biochemical parameters in patients undergoing Coronary Artery Bypass Grafting (CABG). The study group consisted of 96 Coronary Artery Disease (CAD) patients who were referred to our clinic for a CABG procedure and from whom sufficient amount of pericardial fluid could be collected. The patients were classified into 3 groups: Stable Angina Pectoris (SAP) (n=27), Unstable Angina Pectoris (USAP) (n=36), and Post-Myocardial Infarction (PMI) (n=33). Levels of CRP, glucose, albumin, total protein, Creatine Kinase (CK), Creatine Kinase-MB (CK-MB), and Lactate Dehydrogenase (LDH) were determined in pericardial fluid samples and in simultaneously collected blood samples from radial artery. The pericardial CRP and LDH levels in the PMI group were higher than in the SAP (p=0.015 and p=0.000, respectively) and USAP (p=0.011, p=0.047) groups. Serum CRP levels in USAP (p=0.014) and PMI (p= 0.000) groups were higher than those in the SAP group. Pericardial albumin levels in the PMI group were higher than in the USAP group (p=0.038). In all groups, the pericardial fluid/serum protein ratio was > 0.5, the LDL ratio was > 0.6, and pericardial fluid LDH concentrations were > 300 mg/dl. CRP level of pericardial fluid was significantly higher in the PMI group than in other groups. However, pericardial fluid LDH levels were higher than blood LDH levels in this group and were also higher than pericardial fluid LDH levels of other groups.

Klippel-Trenaunay syndrome associated with polydactyly.

Klippel-Trenaunay syndrome (KTS) manifests cutaneous vascular nevus, superficial venous varicosities, and hypertrophy of the affected limb. KTS may be associated with other developmental anomalies such as polydactyly, syndactyly, and macrocephaly. We present a case with KTS associated with polydactyly.

The importance of intrapericardial drain selection in cardiac surgery.

INTRODUCTION: To explore the impact of intrapericardial and infracardiac drains on pericardial effusions in cardiac surgery. MATERIALS AND METHODS: Patients undergoing coronary artery bypass grafting were randomized into two groups. At the end of the intervention, an intrapericardial and infracardiac Blake drain was placed in patients in group 1 (n = 97), and an intrapericardial and infracardiac semirigid drain was placed in patients in group 2 (n = 105). In addition, a semirigid drain was placed into mediastinum in all cases. The amount of drainage was calculated at six different time points postoperatively: postoperative 0 to 2 h, postoperative 2 to 4 h, postoperative 4 to 6 h, postoperative 6 to 12 h, postoperative 12 to 24 h, and postoperative 24 to 48 h. The amount of pericardial effusion was estimated by transthoracic echocardiography after the drains were removed. RESULTS: In all measurements, the amount of drainage from intrapericardial Blake drains was higher, the total amount of drainage being equal to 330.7 +/- 29.4 mL and 193.2 +/- 19.6 mL in the Blake drain and semirigid drain groups, respectively (p = 0.000) [mean +/- SD]. When the drains were removed, the volume of pericardial effusion was 3.86 +/- 0.76 mm in Blake drain group and 7.59 +/- 1.16 mm in semirigid drain group (p = 0.000). The incidence of postoperative atrial fibrillation was 11.3% in the group with Blake drains, and 23.8% in the group with semirigid drains (p = 0.016). CONCLUSION: The more effective drainage obtained with infracardiac Blake drains compared to semirigid drains helps to reduce the amount of postoperative pericardial effusion and the risk of atrial fibrillation.

Surgical management of combined stab injury of the spinal cord and the aorta--case report.

A 32-year-old man presented with a combined penetrating stab injury of the spinal cord and the aorta caused by a knife wound in his back at the low thoracic level. The knife had broken, and part of the blade had been retained in the wound, passing through the spinal canal and into the aortic lumen. The patient was treated in two steps: the aorta was repaired by a thoracotomy, then spinal exploration was carried out through a laminectomy. Because of the tamponade effect of the foreign body, it was necessary to delay removal of the blade until vascular control had been achieved. Any sign of a penetrating body passing through the spine should suggest careful evaluation to detect any visceral injury, and multidisciplinary treatment should be planned.

Assessment of digital ischaemia and evaluation of response to therapy by 99mTc sestamibi limb scintigraphy after local cooling of the hands in patients with vasospastic Raynaud's syndrome.

AIM: Cold induced arteriolar constriction in patients with vasospastic Raynaud's syndrome (VRS) produces temporary digital ischaemia. The aim of this study was to ascertain whether 99mTc sestamibi scintigraphy is useful in the diagnosis and the monitoring of treatment in VRS. METHODS: Fifteen patients with VRS and 20 matched normal controls underwent examination. Twelve patients with VRS received therapy. For each patient, one hand was immersed in iced water for 30s while the other hand served as a control. Ten minutes after cooling, 99mTc sestamibi was injected and imaging was performed 60min later. The per cent decrease of the perfusion (%DP) was calculated by semiquantitative analysis to determine the severity of hypoperfusion. RESULTS: In all patients with VRS, moderate or marked hypoperfusion were seen in 99mTc sestamibi images after exposure to the iced water, while there was minimal or mild hypoperfusion in the control groups. Values for %DP were 46.86 +/- 19.04 and 7.85 +/- 4.53 for the VRS group and normal subjects, respectively. The difference between both groups was statistically significant (P = 0.0000). In 12 treated patients with VRS, pre-treatment and post-treatment %DP values were 51.16 +/- 18.42 and 33.58 +/- 17.83, respectively, and a significant difference was seen between both values (P = 0.001). However, there was still a statistically significant difference between control subjects and post-therapy values (7.85 +/- 4.53 vs. 33.58 +/- 17.83, P = 0.0000). The +/- 95% confidence interval of DP for control subjects was 5.7-10% (chi-squared, P = 0.000). When a DP of 10% was used as a cut-off point, sensitivity, specificity and diagnostic accuracy were 100%, 70% and 83%, respectively, for the 99mTc sestamibi scan. There was also a strong correlation between %DP and the duration of the disease (r = 0.80, P = 0.0003). CONCLUSION: The results of this study indicate that a 99mTc sestamibi scan is a valuable imaging method for the determination of digital ischaemia in vasospastic Raynaud's syndrome, and may play a role in evaluating the response to therapy.

Importance of pulmonary artery perfusion in cardiac surgery.

OBJECTIVE: To investigate the importance of pulmonary artery perfusion in cardiac surgery. DESIGN: Prospective randomized study. SETTING: University hospital. PARTICIPANTS: Patients undergoing cardiac surgery. INTERVENTIONS: Patients in whom the cross-clamp was applied only to the aorta were defined as group 1 (n = 11) and patients in whom the cross-clamp was applied to both the aorta and pulmonary artery were defined as group 2 (n = 11). MEASUREMENT AND RESULTS: Tissue samples obtained from the lower lobe of the left lung before CPB, 20 minutes after cross-clamping, and 20 minutes after declamping were examined under light and electron microscopes. Electron microscopic examination revealed changes in the blood-air barrier, epithelial cells, pneumocytes, and basal membrane were more prominent in group 2. Changes in the leukocyte, neutrophil, and lymphocyte counts of blood samples obtained from the right atrium and right superior pulmonary vein before CPB and 5, 30, 60, and 90 minutes after the removal of clamp were also investigated. The transpulmonary difference was statistically significant at 5 and 30 minutes after declamping in group 1. In group 2, transpulmonary differences continued to be significant at 5, 30, 60, and 90 minutes after declamping. There was no difference between groups in terms of PaO(2)/F(I)O(2) ratio before CPB (group 1: 342.0 +/- 80.0 mmHg, group 2: 349.0 +/- 67.0 mmHg); however, a statistically significant difference was found between the groups 2 hours after declamping (group 1: 418.0 +/- 87.0 mmHg and group 2: 290.0 +/- 110.0 mmHg; p = 0.007). CONCLUSION: Pulmonary artery perfusion was found to be important in cardiac surgery.

Electrophysiological evaluation of phrenic nerve injury during cardiac surgery--a prospective, controlled, clinical study.

BACKGROUND: According to some reports, left hemidiaphragmatic paralysis due to phrenic nerve injury may occur following cardiac surgery. The purpose of this study was to document the effects on phrenic nerve injury of whole body hypothermia, use of ice-slush around the heart and mammary artery harvesting. METHODS: Electrophysiology of phrenic nerves was studied bilaterally in 78 subjects before and three weeks after cardiac or peripheral vascular surgery. In 49 patients, coronary artery bypass grafting (CABG) and heart valve replacement with moderate hypothermic (mean 28 degrees C) cardiopulmonary bypass (CPB) were performed. In the other 29, CABG with beating heart was performed, or, in several cases, peripheral vascular surgery with normothermia. RESULTS: In all patients, measurements of bilateral phrenic nerve function were within normal limits before surgery. Three weeks after surgery, left phrenic nerve function was absent in five patients in the CPB and hypothermia group (3 in CABG and 2 in valve replacement). No phrenic nerve dysfunction was observed after surgery in the CABG with beating heart (no CPB) or the peripheral vascular groups. Except in the five patients with left phrenic nerve paralysis, mean phrenic nerve conduction latency time (ms) and amplitude (mV) did not differ statistically before and after surgery in either group (p > 0.05). CONCLUSIONS: Our results indicate that CPB with hypothermia and local ice-slush application around the heart play a role in phrenic nerve injury following cardiac surgery. Furthermore, phrenic nerve injury during cardiac surgery occurred in 10.2 % of our patients (CABG with CPB plus valve surgery).

The effect of nadroparine on coagulation mechanisms: ultrastructural analysis.

Low molecular weight heparins are widely used in the prophylaxis and treatment of thrombotic disorders. The effect of low molecular weight heparins on coagulation was examined ultrastructurally in an animal model. A test and a control group was formed, each consisting of five rabbits. Nadroparine (225 Institute of Chaoy Unit/kg twice daily) was applied to the test group for 10 days. The control group received 1 ml saline solution subcutaneously. Blood and vascular tissue samples collected at the end of the 10th day were evaluated under a JEM 100 B electron microscope. Platelet degranulation and agglutination was observed in the control group. Fibrin materials were detected in the cytoplasms and surroundings of degranulated platelets. Erythrocyte accumulation was remarkable on the vascular endothelium with intact coagulation periods. In the test group, outer membranes of platelets, hyalomere, and granular structures in the granulomeres were detected to be nearly intact. There were rare erythrocytes in the large vascular lumens. The aggregation phase had occurred but no agglutination was detected. Nadroparine seems to preserve consistency of lipoprotein membranes of platelets and granular structures containing enzymes, which contribute to the coagulation mechanisms.

Autogenous arterial radial-basilic forearm looped transposition.

We describe the use of radial artery as a conduit for arteriovenous hemodialysis access in the forearm. The advantages of this type of fistula are use of autogenous material and its localization because forearm fistula is easily cannulated and is more convenient for the patient. This fistula may be an alternative solution in selected hemodialysis patients for the difficult access in whom superficial arm veins are exhausted and lower extremity access is unsuitable.

Effect of pericardial fluid pro-inflammatory cytokines on hemodynamic parameters.

We investigated the effects of pro-inflammatory cytokines of pericardial fluid on hemodynamic parameters in patients undergoing coronary artery surgery. Seventy-eight patients were included in the study and they were allocated to three groups: group 1, stable angina pectoris (SAP, n = 15); group 2, unstable angina pectoris (USAP, n = 34); group 3, post-myocardial infarction (PMI, n = 29). Pericardial fluid and arterial blood samples were obtained from all patients and interleukin (IL)-1beta, IL-2 receptor, IL-6, IL-8 and tumor necrosis factor-alpha (TNF-alpha) levels were measured. Pericardial IL-1beta concentration (pg/mL) was significantly higher in the USAP group (26.6 +/- 10.9) compared to the SAP (5.0 +/- 0.1) and PMI (5.8 +/- 1.0) groups. IL-2R, IL-6, IL-8 and TNF-alpha concentrations of pericardial fluid were significantly higher than serum in all groups; difference was more prominent in the PMI group compared to the SAP and the USAP groups. Serum IL-1beta concentrations (pg/mL) were significantly higher in the USAP group (21.8 +/- 3.4) compared to the SAP group (5.0 +/- 0.1) and the PMI group (5.4 +/- 1.6). Cardiac index (CI) before opening the pericardial sac was found to be lower in the USAP group (1.6 +/- 0.3 L/min/m2) compared to the SAP (2.2 +/- 0.5 L/min/m2) and the PMI (2.1 +/- 0.5 L/min/m2) groups (p = 0.028 and p = 0.011, respectively). In the USAP group, there was a relationship between reduction of CI and increase of IL-1beta levels in serum and pericardial fluid.

Bilateral popliteal artery aneurysms with rupture and pseudoaneurysm formation on the left.

The rupture of a popliteal artery aneurysm is very rare, and can lead to serious complications if untreated. Any reports of a huge pseudoaneurysm, following rupture of the popliteal artery aneurysm could not be found in a review of the literature. A pulsatile huge mass leading to a deep venous thrombosis, was observed in a 74 years old male patient who for 2 months had had a progressively swollen and painful left leg. On angiographic evaluation, the mass was found to be a pseudoaneurysm originating from a ruptured true aneurysm of the popliteal artery. There was also a small true aneurysm in the contralateral extremity at the same localization. Both the false, and true aneurysms were resected surgically and arterial continuity was established with a synthetic polytetrafluoroethylene graft.

Importance of internal mammary artery perfusion in cardiac ischemia and reperfusion.

PURPOSE: Our purpose was to investigate the changes in antioxidant defense systems due to internal mammary artery (IMA) perfusion during coronary artery bypass graft (CABG) operations in which proximal anastomoses were completed under partial bypass with the aid of a side-biting clamp. MATERIAL AND METHOD: Twenty-five patients to be studied were divided into two groups according to the criterion of whether during proximal anastomoses left internal mammary artery (LIMA) perfusion was applied (n = 15, LIMA group) or not (n = 10, non-LIMA group). The erythrocyte catalase (CAT), superoxide dismutase (SOD), serum lipid peroxidation (LPO) products and whole blood reduced glutathione (GSH) levels were measured in the blood samples taken from the coronary sinus before cardiopulmonary bypass (CPB) (t1), before declamping (t2), at the 5th min after declamping (t3), at the 5th (t4) and 15th (t5) min after removing the side-biting clamp. RESULTS: While erythrocyte CAT enzyme activity decreases in both groups after the basal measurements, no significant difference was detected between the groups. Although the GSH levels did not differ at t1, t2 and t3, they were found to be higher in the LIMA group at t4 (p = 0.006) and t5 (p = 0.021). The erythrocyte SOD enzyme activity decreased after the basal measurements in both groups, but this reduction was less in the LIMA group at t4 (p = 0.034) and t5 (p = 0.018) compared to the other group. LPO products rose in both groups when reperfusion started after declamping. The levels of LPO products were significantly higher at t4 and t5 in the non-LIMA group than the other group (p = 0.011 and p = 0.008). CONCLUSION: If proximal anastomoses of coronary grafts are completed under partial bypass, permitting LIMA perfusion during this procedure will be beneficial to antioxidant defense systems.