Effects of Pooled Platelet Concentrate After Coronary Artery Bypass Graft Surgery in Patients With Dual Antiplatelet Therapy.

BACKGROUND: Dual antiplatelet therapy (DAPT) has become standard first-line treatment of acute coronary syndrome; however, it increases the risk of bleeding complications. The aim of this study was to investigate the benefits of pooled platelet concentrate (PPC) in reducing postoperative bleeding in patients undergoing off-pump coronary artery bypass graft (CABG) after a DAPT loading dose. METHODS: One hundred nine patients who underwent emergent CABG within the first 24 hours after receiving a DAPT loading dose were included in the study and divided into 2 groups: patients who were (group 1, n = 63) and were not (group 2, n = 46) given PPC during the surgery. The amount of bleeding in the postoperative period and the need for blood transfusions were recorded. RESULTS: The mean (SD) surgical drainage amounts were 475.39 (101.94) mL in group 1 and 679.34 (232.03) mL in group 2 (P = .001). The need for surgical revisions was 0% and 15.2% in groups 1 and 2, respectively (P = .002). The median (range) duration of hospitalization after surgery was 4 (4-6) days in group 1 and 6 (4-9) days in group 2 (P = .001). Total transfusions per patient were higher in group 2 than in group 1 (1 [range, 1-4] and 3 [range, 2-7] units, respectively; P = .001). CONCLUSION: Perioperative PPC in patients who had received DAPT reduces postoperative bleeding, the need for blood products, and hospital stay. As a result, it has beneficial effects for early mobilization and improves patient comfort.

Multiple vascular reconstructions during pancreatectomy: Surgical techniques and strategies.

OBJECTIVES: Pancreatic body and tail tumors account for one-third of all pancreatic tumors and can be diagnosed later than pancreatic head tumors because they present symptoms much later. When analyzed, most of them are generally unresectable because they are invaded into adjacent organs and vascular structures. We aimed to present our cases of vascular resection and anastomosis, where isolated tumor resection cannot be performed due to invasion of adjacent vascular structures. METHODS: Between January 2019 and January 2021, the files of eight patients who had one or more vascular invasions due to the pancreatic body and tail tumor and therefore underwent vascular resection in addition to pancreatectomy were accessed. RESULTS: Portal vein and hepatic artery repair were performed in all eight patients. Superior mesenteric artery anastomosis was performed in four patients, inferior vena cava repair was performed in two patients, and renal vein anastomosis was performed in two patients. Primary end-to-end repair, Dacron graft, ring-enforced polytetrafluoroethylene graft, and saphenous vein graft techniques were used during vascular interventions. CONCLUSIONS: We wanted to share our experience with the resection of vascular structures and anastomosis techniques. We believe that the indications of tumor surgery can be improved and redesigned by performing more routinely vascular resections and reconstructions in the future.

Severe methemoglobinemia following intravenous lidocaine administration during coronary artery bypass surgery: The use of methylene blue and extracorporeal membrane oxygenator.

A 63-year-old male patient underwent coronary artery bypass surgery under cardiopulmonary bypass. Preoperative test results were all normal. During surgery, sudden methemoglobinemia developed after the intravenous administration of lidocaine which was used to prevent arrhythmias. In the intensive care unit, methylene blue was given to the patient and an extracorporeal membrane oxygenator was used to correct deep hypotension and worsening hemodynamic parameters. However, the patient died from multiorgan failure secondary to hypoxia. In conclusion, many factors may play a role in the etiology of methemoglobinemia. Treatment options are limited. Methylene blue is used as an effective method in the treatment. Lidocaine is one of the most common drugs used in the practice of cardiology and cardiovascular surgery. Therefore, the possibility of developing methemoglobinemia should be always kept in mind.

Paracardiac gossypiboma (textiloma) in 2 patients.

Gossypiboma, also called textiloma, results when a cotton matrix such as a gauze pad or surgical sponge is left in a body cavity after surgery. The diagnosis of gossypiboma can be challenging. In symptomatic patients, operative removal of the pad or sponge is recommended; however, the decision to operate might be less immediately clear in asymptomatic patients. We report the cases of 2 patients in whom we diagnosed paracardiac gossypiboma. In addition, we briefly review other cases and discuss the treatment of asymptomatic patients.

The role of the preoperative screening of sleep apnoea by Berlin Questionnaire and Epworth Sleepiness Scale for postoperative atrial fibrillation.

BACKGROUND: Undiagnosed obstructive sleep apnoea (OSA) is a risk factor for postoperative atrial fibrillation (POAF) as well as for heart disease in general. This necessitates screening during preoperative assessment to facilitate the implementation of strategies to minimise the postoperative risk. Overnight polysomnography is the "gold standard" for the diagnosis of OSA but may be impractical during preoperative assessment, and so questionnaires may be useful for screening OSA. The Berlin Questionnaire (BQ) and Epworth Sleepiness Scale (ESS) are two of the widely prescreening tools for persons who may suffer from sleep disorders. Thus, screening for and treating OSA as part of the routine preoperative evaluation of cardiac surgical patients may be a useful strategy for preventing POAF. OBJECTIVE: We investigated whether there is an association between POAF and sleep disorders evaluated by the BQ and ESS in this settings. METHODS: In 73 consecutive patients undergoing CABG with cardiopulmonary bypass, preoperative clinical characteristics and operational data were examined. During the clinical evaluation, all patients answered the ESS and BQ voluntarily upon admission. Patients were continuously monitored for the occurrence of sustained postoperative AF while hospitalised. RESULTS: There were 33 patients with POAF and 40 patients without POAF as age- and gender-matched controls. The prevalence of high score in ESS was higher in POAF group compared to control group (52% vs 27%; p: 0.030). There was a higher prevalence of high risk for OSA in BQ in the POAF group (58% vs 34%; p: 0.044). CONCLUSION: Preoperative questionnaire-based diagnosis of OSA by the simple BQ and ESS may be useful in predicting POAF, and can be easily incorporated into routine screening of surgical patients undergoing CABG operation.

Does on-pump normothermic beating-heart valve surgery with low tidal volume ventilation protect the lungs?

BACKGROUND: Postoperative pulmonary dysfunction following cardiopulmonary bypass (CPB) usually develops secondary to the inflammatory process with contact activation, hypothermia, operative trauma, general anesthesia, atelectasis, pain, and pulmonary ischemia/reperfusion due to cross-clamping. The aim of the present study was to evaluate the effects of an on-pump, normothermic, and beating-heart technique and of low-volume ventilation on lung injury. METHODS: We compared the results for 20 patients who underwent operations with an on-pump, normothermic, and beating-heart technique of mitral valve surgery with low-volume ventilation (group 1) with the results for 23 patients who underwent their operations with an on-pump, hypothermic cardiac-arrest technique (group 2). In both groups, blood samples were collected from the right superior pulmonary vein, and inflammation and oxidative stress markers (malondialdehyde, lactic acid, platelet-activating factor, and myeloperoxidase) were studied. RESULTS: Malondialdehyde, myeloperoxidase, and lactate values were significantly lower in group 1 than in group 2 just before the termination of CPB (P < .05). We observed no differences between the 2 groups with regard to values for platelet-activating factor. CONCLUSIONS: Inflammation and oxidative stress markers were lower in the group of patients who underwent beating-heart valve surgery with low-volume ventilation. These results reflect less of an ischemic insult and lower inflammation compared with the results for the patients who underwent conventional operations.

Beating heart versus conventional mitral valve surgery.

OBJECTIVES: The present study aimed to compare the results of beating heart technique and conventional mitral valve surgery (MVS). METHODS: Three hundred and nineteen patients who underwent MVS between April 2005 and December 2006 were enrolled in the study. While 125 patients underwent beating heart MVS (group 1), the conventional approach was used for 194 patients (group 2). Of those patients who underwent beating heart MVS, 75 underwent MVS without cross-clamping the aorta. Coronary sinus retroperfusion was used during surgery in the remaining 50 patients. The right anterolateral thoracotomy was performed in nine out of the 29 patients requiring re-operation, while resternotomy was performed in 20. RESULTS: No significant differences were shown between the groups in the preoperative period in terms of the Parsonnet mortality score, Ontario mortality score, and length of intensive care stay. However, there were significant differences with respect to EuroSCORE risk score, EuroSCORE mortality, and Parsonnet risk score, and length of hospital stay according to Ontario risk scoring. It was established that the patients in group 1 had a shorter length of hospital stay [group 1: six days (range, 4-37 days); group 2: 10 days (range, 4-62 days)]. Group 1 was observed to have shorter time periods when the groups were compared regarding operative time [group 1: 130 min (range, 100-270 min); group 2: 240 min (range, 100-360 min)], cross-clamping (XCL) time [group 1: 27.5 min (range, 3-99 min); group 2: 60.5 min (range, 30-163 min)], and cardiopulmonary bypass time [group 1: 57 min (range, 22-150 min); group 2: 90 min (range, 39-388 min)]. There were also significant differences in favor of group 1 in terms of postoperative need for inotropic support [group 1: 26 patients (16%); group 2: 68 patients (35%)]. Although there were no statistically significant differences in the groups in terms of mortality rates according to the Parsonnet scoring system, with the exception of the moderate risk group, it was noted that the mortality rates in the beating heart group were lower. CONCLUSIONS: This study concluded that beating heart MVS can be performed successfully, particularly for patients at higher risk which will lead to increased morbidity and mortality in postoperative period.

Blood cyst of the right ventricle presenting as recurrent high fever and chills in an adult.

Blood cysts are uncommon primary cardiac tumors, frequently encountered in pediatric patients, but extremely rare when found in adults. Due to the considerable risks of embolization and obstruction of the blood flow, surgical removal is preferred. Herein, we report a case of blood cyst of the right ventricle, presenting as recurrent fever and chills in an adult patient.

On-pump beating heart mitral valve surgery without cross-clamping the aorta.

BACKGROUND AND AIM: Cardiac reperfusion injury is a well-described complication occurring after ischemia or following cardioplegic arrest. Various strategies have been developed to prevent ischemic reperfusion injury. The aim of this study was to assess the efficacy and applicability of the on-pump beating heart mitral valve surgery without cross-clamping the aorta in order to prevent reperfusion injury. METHODS: The prospective study (between April 2005 and December 2006) included 88 consecutive patients who underwent mitral valve surgery. The operations were carried out on a beating heart using normothermic cardiopulmonary bypass without cross-clamping the aorta, therefore perfusing the heart antegradely through the aortic root. Venting the heart from the aorta and the pulmonary vein provided adequate visualization of the operative field. RESULTS: Seventy-eight patients (88.6%) underwent mitral valve replacement and 10 patients (11.3%) underwent mitral valve repair with this technique. Concomitant surgery was required in 29 patients (32.9%). Twenty-five patients (28.4%) had also undergone previous open heart surgery. Mean cardiopulmonary bypass time was 57.4 +/- 18.4 minutes. Mean duration of ventilation was 12.2 +/- 3.5 hours, mean intensive care unit stay was 1.3 +/- 1.6 days, and mean hospital stay was 6.9 +/- 4.5 days. One-year survival was 96.6% for all causes of mortality. CONCLUSIONS: In this study, we showed that on-pump beating heart operations without cross-clamping is an acceptable surgical choice for mitral valve disease. Complication rates are low and perioperative mortality is lower than that generally reported with conventional technique.

Levosimendan for ischemic preconditioning in thoracic aortic aneurysm repair.

BACKGROUND AND AIM: Postoperative neurologic deficit is the most devastating complication after surgical thoracic aorta repair. Cerebrospinal fluid drainage and some medications are used for spinal cord protection during and after the operation. METHODS: A 25-year-old patient applied to our clinic with a traumatic descending aortic aneurysm. We performed a surgical repair for the aneurysm but could not achieve to place a lumbar catheter to provide cerebrospinal fluid drainage. Levosimendan was chosen for spinal cord ischemic preconditioning because of its vasodilatory effects. RESULTS: Postoperative course was uneventful. Hemodynamic and neurologic complication was not observed, and the patient was discharged from the hospital in the postoperative 5th day. CONCLUSIONS: Levosimendan can be used for preconditioning and spinal cord protection from ischemic injury during descending aorta repair. We clearly benefit from the vasodilator peculiarity of the drug for improving spinal cord perfusion.

Aortic valve replacement with on-pump beating heart technique.

BACKGROUND: The aim of this study was to assess the efficacy and applicability of on-pump beating heart aortic valve replacement with retrograde coronary sinus (CS) warm blood perfusion. METHODS: The prospective study included 14 consecutive patients who underwent aortic valve replacement with mechanical prosthesis using retrograde CS perfusion. The operative variables and early outcome of this procedure are presented. RESULTS: Retrograde CS perfusion and venting the heart from the pulmonary vein provided good visualization of the operative field and performance of the operations without any difficulty. Partial oxygen pressures of CS perfusion blood and the returning blood from the coronary ostia were 288.5 +/- 34.4 and 39.6 +/- 4.6 mmHg, respectively. Postoperative peak creatine kinase-MB and troponin T values were mean 77.0 +/- 63.6 IU/L and mean 0.8 +/- 0.7 ng/mL, respectively. No mortality or major complication was observed and all the patients were discharged from the hospital in good condition. CONCLUSIONS: On-pump beating heart aortic valve replacement with retrograde CS warm blood perfusion is a good surgical option, and has the advantage of maintaining physiologic condition of the heart throughout the procedure.