Do preoperative C-reactive protein and mean platelet volume levels predict development of postoperative atrial fibrillation in patients undergoing isolated coronary artery bypass grafting?

INTRODUCTION: Atrial fibrillation (AF) after coronary artery bypass grafting (CABG) operation is associated with increased risk of prolonged hospitalisation, health expenses and adverse clinical outcomes. AIM: To investigate the relationship of atrial fibrillation after an isolated coronary artery bypass operation with levels of mean platelet volume and C-reactive protein. MATERIAL AND METHODS: Among 1240 patients who underwent operations for isolated coronary artery bypass grafting with cardiopulmonary bypass between January 2007 and May 2014, 1138 (91.8%) patients with preoperative normal sinusal rhythm were enrolled in the study. Patients were assigned to group 1 (n = 294) comprising patients who developed atrial fibrillation in the first 72 postoperative hours or group 2 (n = 844) comprising patients who remained in normal sinusal rhythm in the postoperative period. RESULTS: The incidence of postoperative atrial fibrillation was 25.8%. The preoperative mean platelet volume (fl) and C-reactive protein (mg/dl) values in group 1 were 9.1 ±0.5 and 1.1 ±0.9 respectively, while these values were 8.3 ±0.6 and 0.5 ±0.3 respectively in group 2, which was statistically significant (p = 0.0001). Length of stay in the hospital (p = 0.0001) was higher in group 1. The values of mean platelet volume (fl) and mean C-reactive protein (mg/dl) were 9.9 ±0.9 and 30.9 ±3.4 respectively in group 1, while the values of mean platelet volume (fl) and mean C-reactive protein (mg/dl) were 8.8 ±0.6 and 24.9 ±4.8 respectively in group 2 (p = 0.0001 for mean platelet volume, p = 0.0001 for C-reactive protein). The difference between the groups was statistically significant in terms of postoperative neurologic events (p = 0.0001) and hospital mortality (p = 0.001). Increased C-reactive protein and mean platelet volume levels were found to be independent predictors of postoperative atrial fibrillation. CONCLUSIONS: In our study, elevated preoperative mean platelet volume and C-reactive protein levels were associated with development of postoperative atrial fibrillation.

Is Carotid Artery Stenting an Alternative to Simultaneous Carotid Endarterectomy Performed for Carotid Artery Stenosis in Patients Undergoing Isolated Coronary Bypass Surgery?

BACKGROUND: Treatment method in patients with coronary artery disease undergoing coronary bypass surgery with accompanying carotid artery disease is still a hot topic among clinicians. This study is designed to investigate if there is an effect on myocardial infarction, cerebrovascular events and mortality during postoperative period of simultaneous carotid endarterectomy with coronary bypass surgery compared to staged carotid artery stenting before coronary bypass surgery. METHODS: 102 patients (79 male, 23 female) who underwent simultaneous carotid endarterectomy with coronary bypass surgery or staged carotid artery stenting with coronary bypass surgery in the same center with the same surgical team were divided into 2 groups and retrospectively reviewed. Group 1 (n = 71) had coronary artery bypass surgery under general anesthesia with carotid endarterectomy followed by cardiopulmonary bypass with heart team decision. Again with heart team decision, Group 2 (n=31), patients at high-risk for carotid endarterectomy (serious cardiac disease, severe chronic obstructive pulmonary disease, superiorly located lesions), received carotid artery stents in the interventional radiology department and a month later, coronary bypass surgery was performed with cardiopulmonary bypass under elective conditions. RESULTS: Median of patient age was 67.5 (45-83) years. Twenty-two patients (31%) in Group 1 and 19 patients (56.3%) in Group 2 had neurological symptoms, which was statistically significant (P = .004). During the early postoperative term, three patients (4.2%) in Group 1 and two patients (6.5%) in Group 2 died (P = .64). Five patients (7.0%) in Group 1 and two patients (6.5%) in Group 2 developed neurological symptoms during the early postoperative term (P > .05). Likewise, two patients (2.8%) in Group 1 and five patients (16.1%) in Group 2 developed myocardial infarction following carotid intervention (P = .03). CONCLUSIONS: In patients with significant carotid artery stenosis undergoing coronary bypass surgery with cardiopulmonary bypass, in comparison to simultaneous carotid endarterectomy with coronary bypass technique and carotid artery stenting followed with coronary bypass technique showed no difference in combined endpoint (postoperative myocardial infarction, neurological events, and mortality). With proper tools and according to the decisions made by heart teams, both management strategies can be safely performed.

Mitral valve replacement in an adult with left pulmonary agenesis.

Pulmonary agenesis is associated with the absence of pulmonary vessels, bronchi, or parenchyma. This condition usually occurs between the 4th and 5th week of gestation during the embryonic phase. Etiopathogenic factors associated with pulmonary agenesis are not fully understood. In the literature, genetic and teratogenic factors, viral infections, and vitamin-A deficiency are shown to be associated with pulmonary agenesis [Malcon 2012]. This condition may be seen unilaterally or bilaterally. Although the precise rate of incidence is unknown, it is estimated to occur in one of every 10,000 to 12,000 live births [Yetim 2011]. There is a 1.3:1 female predominance with unilateral agenesis [Halilbasic 2013].

Preoperative Platelet to Lymphocyte Ratio Is Associated with Early Morbidity and Mortality after Coronary Artery Bypass Grafting.

OBJECTIVE: To investigate the association of platelet to lymphocyte ratio to mortality and morbidity after coronary artery bypass grafting operation. METHODS: We evaluated records of 916 patients who underwent coronary artery bypass grafting operation between January 2009 and May 2014 retrospectively. Patients were grouped as Group 1 (n = 604) if the platelet to lymphocyte ratio was above 142 and Group 2 (n = 312) if platelet to lymphocyte ratio was below 142. RESULTS: The number of patients who developed a neurologic event during the hospital stay and in the first postoperative month was 7 (1.2%) in Group 1 and 12 (3.8%) in Group 2 for which the difference was statistically significant (P = .007). Early term mortality occurred in 3 patients (0.5%) in Group 1 and in 10 patients (3.2%) in Group 2 for which the difference was statistically highly significant (P = .001). In univariate and multivariate regression analysis, the preoperative platelet to lymphocyte ratio was determined as an independent risk factor for occurrence of atrial fibrillation in the early postoperative period, reoperation for sternum dehiscence, occurrence of a neurologic event, prolonged stay in the hospital and mortality. CONCLUSION: In this study, elevated levels of platelet to lymphocyte ratio were associated with mortality and morbidity after coronary artery bypass grafting operation.

The role of clopidogrel and acetylsalicylic acid in the prevention of early-phase graft occlusion due to reactive thrombocytosis after coronary artery bypass operation.

BACKGROUND: Reactive thrombocytosis has been reported in 20% of patients after coronary artery bypass grafting (CABG), a frequency that might be related to the high incidence of thrombotic complications. The present study was planned to investigate the effect of combined treatment with clopidogrel and acetylsalicylic acid (ASA) on post-CABG reactive thrombocytosis. METHODS: Included in this prospective, randomized study were 60 patients who underwent CABG operation with a 6-month follow-up. Three study groups were defined: group 1 (n = 20), a control group of patients who have not developed reactive thrombocytosis after CABG surgery; group 2 (n = 20), patients who have developed reactive thrombocytosis and continue taking ASA (300 mg/day); and group 3 (n = 20), patients who have developed reactive thrombocytosis and continue taking ASA (300 mg/day) with the addition of clopidogrel (75 mg/day). RESULTS: The mean ages and sex distributions of the patient groups were similar. There were no significant differences between the groups regarding cardiovascular risk factors, baseline laboratory findings, or intraoperative characteristics. Thrombocytosis disappeared within the first month after the operation in both treatment groups. An evaluation of graft patency in the sixth postoperative month revealed that group 2 had significantly more patients with a "positive" result in the exercise test than group 3 and that group 3 had a lower incidence of graft occlusion than group 2 (P < .01). CONCLUSIONS: Combination antiplatelet therapy with ASA and clopidogrel seems to be more effective than ASA alone for maintaining graft patency in patients with reactive thrombocytosis.

The risk factors affecting the complications of saphenous vein graft harvesting in aortocoronary bypass surgery.

Problems of wound healing are commonly observed after coronary bypass grafting (CABG) operations. Our aim is to determine the prevalence and the predictors of saphenous vein harvesting complications after coronary artery bypass surgery. One hundred twenty six patients operated in the specified period were included in this prospective study. In an early period 3 patients were excluded because of their mortality. Twenty patients were female and 103 were male. Forty three patients underwent an open procedure with one incision (35%), 61 patients also underwent an open procedure but with multiple incisions (49%), and 19 patients underwent a closed procedure with stripper (16%). Complications related with leg incisions after surgery were investigated. Multiple incision technique has the longest (49.28 +/- 14.7 cm; p < 0.001) total incision length (compare to single incision and stripper technique). As incision length increases, the incidence of drainage (p < 0.01), pain score (p < 0.05), hematoma (p < 0.05) and diffuse ecchymosis (p < 0.05) were increased. Drainage was seen more frequently in female (p < 0.001) and diabetic patients (p < 0.05). Sex (p < 0.001) and incision length (p < 0.05) have been found independent risk factors for drainage complication. Superficial infection (p < 0.05), pain (p < 0.05) and dehiscence (p < 0.05) were significantly higher in female patients. As the incision length of the multiple incision technique became longer, the risk of drainage, pain, hematoma and diffuse ecchymosis were increased. The significantly increased risk for wound complications were also seen in female gender, diabetic and obese patients.

Comparison of the usage of intravenous iloprost and nitroglycerin for pulmonary hypertension during valvular heart surgery.

BACKGROUND: Pulmonary hypertension secondary to valvular heart disease is a cause of acute right heart failure during valve replacement operations. This study compares the hemodynamic effects of intravenous use of iloprost and nitroglycerin in patients with pulmonary hypertension undergoing valvular replacement surgery. We sought to determine the acceptable doses of these medications for use in surgery to decrease mean pulmonary artery pressure to <30 mmHg without causing systemic side effects. The plasma nitric oxide levels that were obtained from pulmonary mixed venous blood have been compared to demonstrate the difference in the action mechanism of these drugs. METHODS: Eighteen patients undergoing mitral or aortic and mitral valvular replacement with pulmonary hypertension >25 mmHg were included in the study. The 2 groups received iloprost or nitroglycerin via a central pulmonary catheter, and the hemodynamic parameters were evaluated before incision (T1), 10 minutes after chest opening (T2), and 5 minutes and 20 minutes after cardiopulmonary bypass (T3 and T4). The plasma nitric oxide levels were obtained from the mixed venous blood at the T1 and T4 intervals. RESULTS: The data have been analyzed for each group and for repeated measurements of hemodynamic parameters at T1-T4 time points. The analysis of hemodynamic parameters before (T1 and T2) and after (T3 and T4) bypass showed similar responses depending on the use of either iloprost or nitroglycerin. The administration of iloprost after bypass (T3) at a dosage of 1.25 to 2.5 ng/kg per minute reduced mean pulmonary artery pressure (from 28.8 +/- 7.89 to 20.63 +/- 6.39 mmHg) and pulmonary vascular resistance (from 226.88 +/- 101.93 to 118.00 +/- 82.36 dyn sec cm -5) better than nitroglycerin at a dosage of 0.5 to 1 microg/kg per minute (from 23.20 +/- 5.20 to 18.50 +/- 5.10 mmHg and from 160.80 +/- 39.76 to 137.40 +/- 56.54 dyn sec cm -5, respectively). Iloprost causes significant increase in cardiac output (from 4.91 +/- 0.91 to 5.49 +/- 0.91 L/min) compared to nitroglycerin (from 5.23 +/- 0.80 to 5.27 +/- 0.74 L/min). The plasma nitric oxide levels of the iloprost group did not show an increase from T1 to T4, whereas the nitroglycerin group levels did (P <.05). CONCLUSIONS: Intravenous use of both iloprost and nitroglycerin effectively reduces mean pulmonary artery pressure, although only the iloprost group was accompanied by an increase in cardiac output. During operation, where abrupt management of pulmonary hypertension is required, systemic use of iloprost or nitroglycerin at appropriate doses via a pulmonary artery catheter offers adequate relief of hypertension and is well tolerated without any significant adverse effects. The plasma nitric oxide levels did not rise with the use of iloprost.

Novel approach to aortic cannulation suturing: tangential suture technique.

BACKGROUND: Pursestring suture for ascending aortic cannulation in open heart surgery that requires cardiopulmonary bypass may cause serious events, especially in patients who have a thin or calcific aorta. We introduce a novel suturing method, called the 'tangential suture technique', and submit our clinical experience. METHODS: Adult patients undergoing cardiopulmonary bypass were included in this study. Patients in whom the tangential suture technique was applied (Group A; n = 146) were compared with patients in whom the classic pursestring technique was applied (Group B; n = 152). RESULTS: The age (38 +/- 11 years vs 36 +/- 10 years), sex (males 65.1% vs 62.5%) and operation types were similar in both groups. Although the difference was not significant (P > 0.05), subadventitial haematoma occurred more frequently in Group B (13 patients; 8.6%) than in Group A (3 patients; 2.1%). However, none in Group A required opening the adventitia. No aortic dissection was observed in peri- or postoperative periods in either group. In Group B, seven (4.6%) patients required repair by suture after tying of pursestring sutures following decannulation because of bleeding, while none was required in Group A (P = 0.0156). CONCLUSIONS: Tangential suture technique allows the needle to take a longer segment from the media layer while decreasing the likelihood of entering the lumen. Because the tract of the suture almost perfectly fits to the needle curve, tissue injury is less, even on fragile aortas, and this ensures more stable closure of the hole when the suture is tied following decannulation. By considering both its theoretical advantages and our clinical experience, we believe tangential suture technique should be preferred to the classic method.

A novel reporting approach to coronary angiography: "segmental coding system".

BACKGROUND: A new systematic reporting system for coronary angiography has been developed, which is capable of describing any visible intraluminal or extraluminal conditions with the exact coordinates. METHODS: In this method, called "segmental coding system"(SCS), the part of the artery that is located between its two subsequent branches is considered to be an "angiographic segment". Conditions are localized according to their relationship with these angiographic segments and the anatomic border of the segments (coronary ostiums, primary, secondary and tertiary branches, grafts and proximal and distal anastomosis sites). They are also described by using a special coding system that consists of letters, numbers and signs. SCS can supply the name (stenosis, occlusion, contour deformity, aneurysm, rupture, anatomical variation, existence of stent, etc.) and the exact localization (coordinates) of the condition with its properties; filling direction, and the collateral system that fills the vessel. RESULTS: We applied SCS to more than 500 cineangiograpies. According to our experience, SCS provides more objective, detailed, and even correct information than the current narrative reporting system. SCS also offers many extra advantages. (a) It can describe all imaginable types of lesion combinations. (b) All of the existing conditions can be listed without missing. (c) The definitions are very precise and clear. They can easily be understood by everyone in the same way. (d) It is more advantageous on archiving, searching the database, and comparing the subsequent reports for the same patient. (e) In the future, by using specially tailored software, personal and detailed angiographic images will be reproduced from the SCS data. CONCLUSIONS: By being introduced into clinical practice, we believe, SCS will prove a very useful tool for both surgeons and cardiologists.

Comparative assessment of chordal preservation versus chordal resection in mitral valve replacement for mitral stenosis (long-term follow-up: 8 years).

Carrying out a mitral valve replacement (MVR) while preserving all chordae tendineae in patients with mitral regurgitation has been proven beneficial to the left ventricular performance. To evaluate the effectiveness of this technique in patients with mitral stenosis, a comparison of the echocardiographic data between patients who were operated on using this technique (Group Preservation = GroupP, n = 15), and those operated on using the conventional method of MVR (Group Conventional = GroupC, n = 15) was made. All patients were examined before surgery, 6 months after surgery and 8 years after surgery. The study population was limited to patients who had no evidence of coronary artery disease, aortic stenosis and/or regurgitation and patients who had pure mitral stenosis. Echocardiographic measurements obtained both 6 months and 8 years postoperatively revealed a significant decrease in the left ventricular ejection fraction in GroupC (61.33+/-9.29% preoperatively, 53.2+/-10.3% postoperatively). The difference between the decrease in the left ventricular ejection fraction of the two groups was statistically significant (-0.71+/-6.28% in GroupP, -8.07+/-13.35% in GroupC). There was no evidence of prosthetic valve dysfunction and no operative deaths. Two patients died in GroupP, 3 patients died in GroupC within the 8 year period. The conclusion was reached, that if suitable, mitral valve replacement while preserving the chordae tendineae is expected to have a beneficial effect on postoperative left ventricular performance in patients with mitral stenosis.

Systematic approach on postoperative care of the cardiac surgical patients.

With the medical advances and rising expectations among cardiac surgeons and patients, older and sicker patients now undergo ever more complex operations. However, fortunately, postoperative care of cardiac surgical patients also have shown important changes parallel to the surgical improvements. Although, the events within the operating room are accepted as the main determinants for the faith of the patient, some patients, who are very ill upon arrival in the intensive care unit, may have a good long-term prognosis when postoperative care is meticulously provided. Conversely, patients who are doing well as they leave the operating room may be put at significant risk for complications by poor postoperative management. In this paper, we draw an outline of systematical approach of intensive care of cardiac surgical patients and summarize a practical manual for physicians. By applying this approach effectively, it should be expected that, the clinician is able to recognize an impending disaster earlier, initiate the proper treatment timely, and increase patients chances of survival.

Creating a bicuspid valve from the aortic wall: a new surgical approach on aortic valve disease (in vitro study).

We described a new technique (called 'bicuspidization'), which is performed by using autogenous material, without replacement of the aortic valves for the surgical treatment of aortic stenosis and/or insufficiency and tested it in in vitro sheep model. Different stress conditions were simulated by applying three different flow patterns (hemodynamic challenge tests) successively by using a centrifugal pump. It was demonstrated that the competency of the new bicuspid valves was excellent (zero insufficiency). There was a 10-11 mm Hg-increase on trans-valvular gradient comparing the normal hearts. The autogenous bicuspid valve has not blocked the way of the coronary flow in the closed position.

Effects of seasonal variations on coronary artery surgery.

BACKGROUND: In this study, we compared profiles and early results of patients who underwent coronary artery bypass graft surgery (CABG) during the winter season with those who underwent CABG during the summer season. We also investigated whether possible seasonal variations in performance of health care professionals had any effects on surgical outcome. METHODS: The data from patients who had undergone CABG surgery in the winter (group A) and summer (group B) seasons of the period from December 1998 to August 2001 were analyzed retrospectively. Preoperative, perioperative, and postoperative data were compared. Preoperative factors analyzed included sex, age, diabetes mellitus, hypertension, New York Heart Association status, unstable angina pectoris, and left ventricle ejection fraction. Perioperative factors included graft number, internal mammary artery use, cross-clamp time, and cardiopulmonary bypass time. Postoperative factors included mediastinal reexploration, blood use, inotropic support, intraaortic balloon pump support, perioperative myocardial infarctus, cardiac arrest, infection and other complications, duration of hospital stay, and early mortality. RESULTS: The preoperative demographic data were identical in the 2 groups, with the exception of incidence rate of hypertension (26.8% in group A versus 15.7% in group B, P <.01). The incidence rates were higher in group B than group A for postoperative infection (8.8% versus 5.2%, P <.05), mediastinal reexploration for bleeding (6.9% versus 4.2%, P <.05), and transfusion blood use (7.3 +/- 6.2 U/patient versus 6.0 +/- 3.9 U/patient, P <.05). There were no differences between the 2 groups in early mortality rates. CONCLUSION: Despite the fact that frequency and occurrence of cardiovascular events traditionally have been reported to be higher in the winter than the summer, our data show no major differences in early surgical outcome among those patients who had undergone CABG in the winter or summer. We did not encounter any seasonal patterns. However, an interesting finding was that the patients who underwent surgery in the summer had a higher incidence of infection and bleeding.