Sialic acid is a marker of lung injury following lower extremities ischemia/reperfusion.

OBJECTIVE: This study tests whether sialic acid is a mediator of the lung injury following lower extremity ischemia/reperfusion (I/R). Design. Prospective randomised study. MATERIALS AND METHODS: Thirty-one Sprague-Dawley rats were randomised into four groups: group 1, aorta was exposed but not clamped; group 2, aorta clamped for 3 h, followed by 1 h of reperfusion; group 3, 50 mg/kg pentoxifylline administrated before the aorta was clamped; and group 4, 1 mg/kg dexametasone administrated before the aorta was clamped. Serial arterial blood samples for blood gas, tumor necrosis factor-alpha (TNF-alpha), and total SA (TSA) assay were obtained. The lungs were removed and histologically examined for evidence of injury. RESULTS: Groups 2, 3, and 4 had significantly higher peak serum TSA concentrations compared with groups 1 (group 1 vs. 2, p=0.001; group 1 vs. 3, p=0.002; group 1 vs. 4, p=0.001). Group 3 had lower peak serum TSA concentration. Groups 2 and 4 had significantly higher peak serum TNF-alpha concentrations (p=0.0001) compared with groups 1 and 3. Group 3 had lower peak serum TNF-alpha concentration. Lower TSA and TNF-alpha levels are associated with lesser degrees of lung injury. CONCLUSIONS: TSA and TNF appear during events that lead to lung injury following lower extremity I/R.

Coronary reoperations without the use of cardiopulmonary bypass.

BACKGROUND: Reoperations of coronary artery surgery still carry a higher mortality and morbidity rate, compared to primary revascularization procedures. Coronary artery bypass reoperations without the use of cardiopulmonary bypass (CPB) is a potential strategy that has been developed to decrease mortality and morbidity. MATERIALS AND METHODS: Between 1978 and 2000, 113 patients were reoperated for coronary artery revascularization, 32 (28.3%) cases on beating heart without the use of CPB (Group II) and 81 (71.7%) cases under CPB and cardioplegic arrest (Group I). Mean age of Groups I and II were 61.3+/-5 and 57.4+/-7.3 years, respectively. RESULTS: Statistically significant difference was found between the two groups, favoring off pump surgery in the early postoperative findings with respect to low cardiac output, postoperative myocardial infarction and postoperative hospitalization duration until discharge. Operative mortality was not statistically different between groups and these figures for cardiopulmonary and off pump groups were 11/81 (13.5%), 1/32 (3.1%), respectively. CONCLUSION: Reoperations of coronary artery revascularization surgery without the use of CPB is more economic, necessitating less manipulations, free of side effects of CPB, less time consuming surgical procedure compared to reoperations performed under standard techniques. When performed with a refined technique and true indications, off pump coronary reoperations have mortality and morbidity advantages over the surgery performed under CPB, improvements in techniques and instruments off pump strategy must be in the surgeons armamentarium in coronary reoperations.

Inhibition of systemic inflammatory response with sodium nitroprusside in open heart surgery.

BACKGROUND: A nitric oxide donor, sodium nitroprusside has been reported to reduce the inflammatory response during cardiopulmonary bypass (CPB). To investigate this, a double-blind and prospective study was conducted. METHODS: Twenty patients with multi vessel coronary disease were randomly chosen to form study (SNP) and control groups. In the SNP group, 0.5 microg/kg/min sodium nitroprusside were administered for 20 min right after the release of the aortic crossclamp. Mac-1 (CD11b/CD18) leukocyte adhesion molecule expressions, interleukin-6 levels were measured from radial artery blood as well as leukocyte and platelet counts in both groups at 6 different time points: a) before anesthesia, b) after heparin administration, c) after aortic crossclamp release, d) after protamine administration, e) 3 hours after the termination of CPB, f) 24 hours after the termination of CPB. RESULTS: The increase in Mac-1 expressions were not different between the two groups at any time point except the measurements after the administration of protamine. At this time point, Mac-1 expressions were not different between the groups (99.8+/-30.7 vs 134.6+/-95.1%, p=0.076), but higher when compared with the preinduction levels. IL-6 levels for SNP and control groups was 89+/-43 and 215+/-131 pg/dL, respectively (p=0.016) 3 hours after the termination of CPB. Twenty-four hours after the termination of CPB, IL-6 levels were still significantly higher in the control group (47+/-27 vs 111+/-68 pg/dL, p=0.039). Leukocyte and platelet counts were not different at any time point between the groups. CONCLUSIONS: Systemic inflammatory response in patients undergoing CPB can be reduced to a certain level with sodium nitroprusside, especially the activation of vascular endothelial cells can be inhibited, but activation of leukocytes still takes place.

Sialic acid is an indicator of inflammation due to cardiopulmonary bypass but not myocardial damage.

BACKGROUND: The aim of the present study was to investigate whether serum sialic acid is associated with the inflammatory response of cardiopulmonary bypass (CPB) or not, since cardiopulmonary bypass is known to produce a systemic inflammatory syndrome. METHODS: In 20 patients in whom elective coronary bypass grafting was done, arterial and coronary sinus blood sampling was done simultaneously. The timing of samplings was 8-10 min after the institution of CPB, just before the application of aortic clamping (T1) and 2 min after cross clamp removal (T2), when there was coronary circulation, but no myocardial activation. RESULTS: Sialic acid, CK-MB, lactate levels were significantly higher at T2 than those at T1 for both arterial and coronary sinus samples. Increase at T2 time point for SA, CK-MB and lactic acid at coronary sinus were closely correlated with the systemic increase of these substances also. Actually, increase of systemic and coronary sinus CK-MB levels was also correlated with the duration of aortic cross-clamping and cardiopulmonary bypass. Probably due to consumption, a negative correlation with the decrease of fibrinogen at coronary sinus was found with the duration of aortic cross-clamping. CONCLUSIONS: Our study showed a strong and consistent association between serum SA concentration and the inflammatory process. There are previous reports that show sialic acid levels associated with ischemic insult to myocardium. We are able to show that serum TSA correlates well with some of the acute phase proteins but this was not true with ischemic markers after cardioplegic arrest.

A case of prosthetic mitral valve endocarditis caused by Brucella abortus.

Endocarditis is a rare but serious complication of brucellosis. We report here a case of Brucella abortus endocarditis occurring on a prosthetic mitral valve. The diagnosis was established by positive serology, the presence of vegetation on the mitral prosthesis and isolation of B. abortus from the blood and valve cultures. The patient was successfully treated with combined medical and surgical therapy.

Is left main coronary artery stenosis a risk factor for early mortality in coronary artery surgery?

It is accepted universally that the treatment of critical left main coronary artery (LMCA) stenosis is surgical revascularization. This study was designed to evaluate critical LMCA stenosis as a risk factor in coronary artery bypass surgery. We compared the surgical results of 760 patients with critical LMCA disease, including 58 cases who were operated under emergency conditions (LMCA-em) and 702 patients who were operated electively (LMCA-el), with randomly chosen 707 coronary bypass patients (CONT-el) without LMCA disease, but who had double- or triple-vessel disease. Another group of patients (n = 99) who were operated on under emergency conditions (CONT-em) but without LMCA disease were also compared with the corresponding groups. The mortality of LMCA-em group and CONT-em group was markedly higher from the other two groups. Univariate analysis revealed that female gender, older age, presence of diabetes mellitus, poor left ventricular function, and the presence of unstable angina were major risk factors for fatal outcome in LMCA-el and CONT-el groups. Age was also a risk factor in LMCA-em group, as well as unstable angina pectoris. The coexistence of critical right coronary artery disease did not affect the early outcome in both groups with LMCA lesions. In the multivariate analysis, critical LMCA disease was not a risk factor for mortality. Logistic regression analysis revealed diabetes [odds ratio (OR): 3.66], poor left ventricular function (higher left ventricle end-diastolic pressure, OR: 1.08), and emergent operations (OR: 5.09) were risk factors for early mortality. Patients with LMCA disease should have surgery promptly for favorable results, because emergency conditions have higher mortality rates.

Results of right coronary artery endarterectomy with or without patchplasty.

We report preoperative and early postoperative findings of 286 coronary bypass patients operated between 1988 and 1998 who had endarterectomy and/or patchplasty to the right coronary artery. In this retrospective study there were 61 cases with only saphenous vein patchplasty to the right coronary artery (patch group), 57 patients who underwent endarterectomy and patchplasty (open-patch group), and 229 patients having closed endarterectomy to the right coronary artery (closed group). A group of 150 patients having a saphenous vein graft to the right coronary artery without endarterectomy were chosen as a control group. Gender, age, family history, smoking history, diabetes, hyperlipidemia, hypertension, nature of the angina, severity of the coronary artery disease, left ventricular functions, preoperative rhythm, and electrocardiographic patterns were evaluated for their effect on early mortality among groups. No significant difference was detected. Positive inotropic and mechanical support need was higher in the closed group at the end of the operation and in the intensive care unit. Duration of cardiopulmonary bypass and clamp time was higher in the open-patch group. Atrial fibrillation in the early postoperative period was more frequent in the patch and closed groups. Complete atrioventricular block development and the need for a pacemaker were higher in the open-patch and closed groups. Non-Q wave myocardial infarction was more frequent in the closed group. Mortality rates were higher in the open-patch and closed groups. We conclude that endarterectomy to right coronary artery should be avoided if possible, and patchplasty with saphenous vein should be preferred.

Bloodstream, respiratory, and deep surgical wound infections after open heart surgery.

Nosocomial infections are one of the most feared complications after open heart surgery. A large retrospective study was conducted to evaluate the nature and scope of the problem. Between 1992 and 1998, 9352 patients who had undergone open heart surgery were evaluated. Bloodstream infections, pneumonia, and deep sternal wound infections were included. Univariate and logistic regression analyses were conducted to identify the high-risk patients that were likely to become infected. Three hundred forty-six infections in 276 patients were diagnosed. Age, preoperative albumin level, banked blood requirement, duration of operation, diabetes mellitus, previous open heart surgery, moderate or severe pericardial adhesions, obesity, postoperative low cardiac output, and postoperative cerebrovascular accident were found to be significant in univariate and logistic regression analyses for infectious outcome. Univariate analysis also revealed additional significant factors: fresh frozen plasma requirement, duration of cardiopulmonary bypass and cross-clamp, preoperative high levels of blood urea and glucose, presence of occlusive peripheral arterial disease, preoperative history of hypertension, and nasal carriage of Staphylococcus aureus. Methicillin resistant S. aureus was involved in 58.4% of the infections. Risk factors should be individualized for patients and every effort should be carried out to minimize infectious outcome.

Septal myectomy in hypertrophic obstructive cardiomyopathy: late results with stress echocardiography.

BACKGROUND: This study was performed to assess the functional capacity of the survivors of septal myectomy for the treatment of hypertrophic obstructive cardiomyopathy in long-term follow-up as assessed by dobutamine stress echocardiography. METHODS: Sixty-nine patients with hypertrophic obstructive cardiomyopathy underwent septal myectomy between 1975 and 1996. The mean age was 25.4 +/- 13.6 years (range, 6-58 years), and 10 of the patients were women. The early mortality was 4.3%. Hospital survivors (95.7%) were followed up for a mean of 43.8 +/- 28.7 months (range, 6-114 months). RESULTS: The postoperative mean functional capacity of the group was 1.47 +/- 0.56. No late deaths were reported. Forty-nine patients (74.2%) were evaluated with standard echocardiographic techniques, and 29 (43.9%) patients underwent dobutamine stress echocardiography. There was a significant decrease in the thickness of the interventricular septum after surgery. The mean preoperative and postoperative septal thickness was 1.99 +/- 0.59 cm (range, 1.3-3.8 cm) and 1.55 +/- 0.41 cm (range, 0.96-2.8 cm), respectively (p < 0.004). The mean posterior wall thickness was significantly less than the preoperative value (p = 0.008) and the left ventricular end-diastolic diameter was slightly greater in the postoperative measurements, but the difference was not significant (p = 0.162). Postoperative left ventricular outflow systolic gradients were reduced significantly when compared with preoperative values (preoperative mean, 78.4 +/- 33.6 mm Hg, range, 50-212 mm Hg versus postoperative mean, 17.9 +/- 15.9 mm Hg: range, 0-40 mm Hg; p < 0.0001). CONCLUSION: Septal myectomy for patients with hypertrophic obstructive cardiomyopathy is a safe procedure with excellent clinical and functional results in the long-term follow-up.

Routine coronary arteriography before abdominal aortic aneurysm repair.

BACKGROUND: As cardiac complications constitute the principal cause of early and late morbidity and mortality after the surgical treatment of abdominal aortic aneurysm (AAA), a prospective study was planned to evaluate the effects of revascularization of coronary arteries on survival after AAA repair during early and long-term follow-up periods. PATIENTS AND METHODS: A total of 125 patients underwent elective repair of AAA between 1986 and 1994. Coronary arteriography was performed in all cases. All cases with critical left anterior descending artery (LAD) lesions underwent a coronary artery bypass operation either simultaneously or shortly before AAA repair. In addition, percutaneous transluminal coronary angioplasty (PTCA) was performed for symptomatic and critical stenosis of arteries other than the LADs, or if noncritical but symptomatic stenosis of the LADs existed. Early and late follow-up data were obtained for all cases, and late-term cumulative survival rates were calculated. RESULTS: Coronary artery lesions were found in 66 (53%) cases. In 24 cases, AAA repairs were performed 2.3 (mean) months after coronary artery bypass grafting (CABG), whereas in 4 cases both procedures were performed simultaneously. PTCA was performed in 4 cases 3 to 4 days prior to the abdominal surgery. Even though the coronary artery lesions were found inoperable in 7 cases, these patients underwent repair of AAA because of rapidly expanding and painful aneurysms. Early mortality rate was 4% (5 cases), in which 3 of these were from the group inoperable for CABG. A mean follow-up of 3.17 years (3 to 87 months) was achieved for all discharged patients. Cumulative survival rates for 6 months and 1, 2, 3, and 6 years were 99%, 99%, 95%, 93%, and 89%, respectively. CONCLUSIONS: The results of this study emphasize the importance of coronary artery revascularization for early, and especially for late, survival after AAA repair.

Vascular complications related to percutaneous insertion of intraaortic balloon pumps.

The hemodynamic effects of intraaortic balloon pumps (IABPs) are well known. The use of IABPs is prone to many complications, including those classified as vascular. These complications are said to be more frequent with percutaneous insertion techniques. These complications and the algorithm for identifying patients who are most likely to suffer vascular complications were evaluated in a retrospective manner in a group of patients that received percutaneous IABPs. The study group consisted of 449 patients. The mean age of these patients was 53.6 +/- 12.8 years (range, 18 to 80 years), and 24.7% were female. The early mortality rate of these patients was 53.2%. The mortality for patients in whom vascular complications developed was significantly higher than that in the patients who did not suffer any vascular complications (65.7% versus 50.8%; p = 0.018). Minor or major vascular complications developed in 17.4% (n = 78) of the patients. There was no statistical difference in the frequency of complications between the patients who received a sheathless IABP and those who received a sheathed IABP. Ischemic complications occurred in 16.6% of the patients who received a sheathless IABP and in 17.6% of the patients with sheathed IABPs (p < 0.05). Diabetic patients (relative risk, 2.5), female patients (relative risk, 1.83), patients with peripheral vascular disease (relative risk, 3.69), and patients undergoing coronary artery bypass operations (relative risk, 2.08) were at increased risk for suffering vascular complications. These risk factors should be evaluated before insertion of an IABP, and routes other than percutaneous femoral insertion are preferred if the patient is IABP dependent.

Pseudoaneurysm of the tibioperoneal trunk.

A young woman with an iatrogenic coagulation defect related to a mechanical mitral valve prosthesis developed a pseudoaneurysm of the tibioperoneal trunk after a minor blunt injury. The importance of minor blunt trauma in such cases and the surgical approach are reviewed.

Surgical approach to pseudoaneurysms with Behçet's disease.

One of the arterial complications of Behçet's disease, arterial false aneurysms, has a sudden onset of symptoms and high mortality risk if left untreated. Four cases with arterial pseudoaneurysms of 3 male patients is reported and the choice of surgical intervention is emphasized. It is underlined that PTFE grafts are the graft of choice in reconstructions for arterial complications of Behçet's disease.

Bilateral triple renal arteries in a patient with iliac artery occlusion: a case report.

Multiple renal artery abnormalities in a surgical patient with iliac artery occlusion is presented in this case report. Angiographic and operative appearance has been reviewed. We found three renal arteries bilaterally. This abnormality has been compared with the literature and the clinical importance has been emphasized.