Effects of levosimendan on isolated human internal mammary artery and saphenous vein: concurrent use with conventional vasodilators.

Graft spasm is a common problem in coronary artery bypass grafting (CABG). In this study, we aimed to investigate the interaction of levosimendan, a novel inodilator, with vasodilator agents that are clinically used for the treatment of graft spasm and with endogenous vasoconstrictors that are thought to play a role in graft vasospasm, in human internal mammary artery (IMA) and saphenous vein (SV). Isolated human IMA and SV segments derived from patients undergoing CABG were suspended in an organ bath. Responses to cumulative concentrations of noradrenaline (NA), serotonin (5-HT), papaverine, nitroglycerin (NG), and diltiazem were recorded before and after 10(-5) m levosimendan incubation (30 min). In addition, cumulative levosimendan responses were taken in vessels precontracted with NA or 5-HT. 10(-5) m levosimendan reduced NA Emax and sensitivity in IMA and SV, and 5-HT Emax responses in IMA. Moreover, levosimendan caused concentration-dependent relaxation in both grafts. Papaverine Emax or sensitivity was not altered by levosimendan neither in IMA nor in SV. Levosimendan diminished NG sensitivity in IMA and Emax responses in SV and decreased diltiazem Emax responses both in IMA and SV. Our results suggest that levosimendan may be used alone for prevention or treatment of graft spasm in IMA or in combination with papaverine in IMA and SV grafts. However, as concurrent administration with diltiazem or NG causes a reduction in relaxation in vitro, we suggest caution should be exercised when using levosimendan in combination with these agents.

Comparison of continuous-flow and pulsatile-flow blood pumps on reducing pulmonary artery pressure in patients with fixed pulmonary hypertension.

Pulmonary hypertension (PH) is considered as a risk factor for morbidity and mortality in patients undergoing heart transplantation. Recently, left ventricular assist device (LVAD) implantation has been increasingly used in reducing pulmonary artery pressure (PAP) in patients with PH unresponsive to medical therapy. Herein, we aimed to compare the efficacy of continuous-flow and pulsatile-flow blood pumps on the improvement of PH in mechanical circulatory support patients. Twenty-seven patients with end-stage heart failure who underwent LVAD implantation surgery were enrolled. Fifteen of them (55.6%) had continuous-flow pump (HeartWare Ventricular Assist System, HeartWare, Inc., Miramar, FL, USA), and 12 of them (44.4%) had pulsatile pump (Berlin Heart EXCOR ventricular assist device, Berlin Heart AG, Berlin, Germany). The efficacy of LVADs on the improvement of PH was compared between continuous-flow and pulsatile pumps by the evaluation of systolic PAP, tricuspid annular plane systolic excursion (TAPSE), right ventricular systolic motion (RVSM), right ventricular ejection fraction (RVEF), and grade of tricuspid insufficiency (TI) for each of the study participants. All of the 15 patients who underwent continuous-flow blood pump implantation surgery (Group 1) were male with a mean age of 46.9 ± 11.7 years, and in pulsatile-flow blood pump implanted participants (Group 2), the mean age was 40.6 ± 16.8 years, all of whom were also male (P=0.259). Mean follow-up was 313.7 ± 241.3 days in Group 1 and 448.7 ± 120.7 days in Group 2 (P=0.139). In Group 1, mean preoperative and postoperative systolic PAP were measured as 51.7 ± 12.2 mm Hg and 22.2 ± 3.4 mm Hg, respectively, while those in Group 2 were 54.5 ± 7.5 mm Hg and 33.9 ± 6.4 mm Hg, respectively. A significantly greater decrease in systolic PAP was noticed in patients with continuous-flow blood pumps (P=0.023); however, no statistically significant difference was found when we considered the change in TAPSE between study groups (P=0.112). A statistical significance in the alteration of RVEF, RVSM, and the grade of TI during study visits was not found between the study groups (P=0.472, P=0.887, and P=0.237, respectively). Although the two studied types of LVADs were found to be effective in reducing PAP in heart transplantation candidates with PH, lesser postoperative systolic PAP values were achieved in patients who underwent continuous-flow pump implantation surgery.

Psychiatric evaluation of children and adolescents with left ventricular assist devices.

OBJECTIVES: To evaluate the psychiatric symptoms of children equipped with a ventricular assist device (VAD) and follow them up for 6 months. With the shortage of donor hearts available for the treatment of end-stage heart failure, VADs have been used to provide temporary treatment until a heart becomes available. VADs provide external sources of power for mechanical circulatory support and are capable of sustaining life over weeks and months. This study provides preliminary details about the psychiatric symptoms and disorders of the first eight children equipped with a VAD in Turkey. METHODS: Eight pediatric patients who recently underwent VAD implantation, aged 1 to 16 years, were evaluated using the Kiddie Schedule for Affective Disorders and Schizophrenia, Child Behavior Checklist, Children's Depression Inventory, Beck Depression Inventory, and State-Trait Anxiety Inventory for Children and followed up for 6 months. RESULTS: In the first evaluation, five participants had a psychiatric disorder diagnosis. Two patients had adjustment disorder with depressive and anxiety symptoms; one had anxiety disorder, not otherwise specified; and two had major depressive disorder. The anxiety and depressive symptom levels in questionnaires were consistent with psychiatric diagnoses. Two patients had heart transplantation during the follow-up period. CONCLUSIONS: To determine and treat psychiatric symptoms and disorders at an earlier stage, it is important for children and adolescents with a VAD and those who have undergone heart transplantation to be evaluated by a multidisciplinary consultation liaison team including psychiatrists, psychologists, consultant nurses, and counselors.

Surgical repair of middle aortic syndrome in a three-year-old patient.

Middle aortic syndrome is a rare variation of aortic coarctation that is localized to the distal thoracic and abdominal aorta, and can involve the visceral and renal arteries. Irreversible organ damage and end-stage congestive heart failure may be the possible harmful complications of this disease in untreated patients. We report a three-year-old patient with diffuse thoracic and abdominal aorta hypoplasia treated with a thoracic to abdominal aortic bypass graft.

Malperfusion remains the major cause of mortality in proximal aortic operations.

BACKGROUND: This study was undertaken to identify the incremental risk factors for early mortality in operations for proximal aortic pathologies. METHODS: Between September 2000 and May 2010, 240 consecutive patients underwent replacement of various portions of the proximal aorta. Mean age was 56 ± 13 years (range 18 to 84) and female/male ratio was 3/7. Operations were performed emergently in 97, urgently in 21, and electively in 122 patients. Thirty-four patients had previous cardiac or aortic operations. Etiology was acute dissection in 102, chronic dissection in 41, degenerative aneurysm in 61, and other factors (endocarditis, pseudoaneurysm, aortitis, etc.) in 36 patients. The ascending aorta was replaced in all patients. In addition, the aortic arch was replaced in 20 and the root was replaced in 106 patients. RESULTS: The in-hospital mortality rate was 10.4% in the overall group (25/240), 21.6% in emergent cases (21/97), 9.5% in urgent cases (2/21), and 1.6% in elective cases (2/122). Morbidity rates were as follows: stroke 2.7%, temporary neurological dysfunction 13.3%, nonoliguric renal failure 3%, dialysis 5.4%, tracheostomy 3.3%, bleeding requiring revision 3.3%. In multivariate analysis, the presence of malperfusion in patients with acute aortic dissection emerged as the incremental risk factor for mortality (p < 0.0001, odds ratio = 10.37). There was no variable associated with stroke. Emergency/urgency of operation did not emerge as incremental risk factors for mortality. CONCLUSION: Immediate outcomes of elective aortic operations for proximal aortic pathologies are excellent. Complicated acute dissections with malperfusion remain the major cause of early mortality.

Reoperative off-pump right subclavian artery to right coronary artery bypass grafting without full sternotomy.

Stenosis or occlusion of a large right coronary artery or its vein grafts in symptomatic patients who underwent previous bypass grafting procedure with patent left-sided grafts is mostly managed by percutaneous interventions. When percutaneous interventions fail, it is a difficult decision to reoperate on a such patient for a single-vessel disease considering the risk of resternotomy. We present our technique which involves small anterior thoracotomy and partial sternotomy.

Chylothorax after thoracoabdominal aneurysm repair: efficacy of somatostatin.

Chylothorax is a rare but serious complication that presents after thoracoabdominal aortic aneurysm surgery. There are insufficient data to reach a consensus on how to manage it. Some researchers have suggested early reoperation for high output drainage. We present the case of a patient who underwent thoracoabdominal aortic replacement and who subsequently developed postoperative chylothorax. High output (>1,000 mL per day) chest tube drainage until postoperative day 4 drastically decreased and stopped in a week with the administration of somatostatin and total parenteral nutrition which helped avoid a major re-exploration. Surgery should be reserved as an option only for patients with persistent leaks that do not respond to somatostatin therapy.

Immediate clinical outcome after prolonged periods of brain protection: retrospective comparison of hypothermic circulatory arrest, retrograde, and antegrade perfusion.

BACKGROUND AND AIM: We aimed to compare the immediate clinical outcome after different cerebral perfusion methods, and examine the factors affecting the mortality and neurological outcome. METHODS: Between 1993 and 2006, 339 patients underwent proximal aortic operations using a period of cerebral protection. Among these, 161 patients (mean age of 55 +/- 12 years) who required cerebral protection longer than 25 minutes were included in the analysis. Ascending aorta with or without root was replaced in all patients. In addition, total arch replacement was performed in 36 patients. All patients were cooled to rectal temperature of 16 degrees C. Hypothermic circulatory arrest without adjunctive perfusion was used in 48 patients. Retrograde or antegrade cerebral perfusion was added in 94 and 19 patients, respectively. The mean duration of total cerebral protection was 42 +/- 17 minutes. RESULTS: Overall mortality was 15.5% (25/161) and did not differ among the perfusion groups. There was no difference in the incidence of overall neurological events, temporary neurological dysfunction, or major stroke among the groups. Multivariate analysis revealed that transfusion of >3 units of blood (p < 0.03) was an incremental risk factor for mortality. History of hypertension (p < 0.03), coexisting systemic diseases (p < 0.005), and transfusion of >3 units of blood (p < 0.04) were predictors of temporary neurological dysfunction. CONCLUSION: In proximal aortic operations requiring prolonged periods of cerebral protection, the mortality and neurological morbidity are not determined by the type of cerebral protection method only. Factors like hypertension and diabetes may play a role in the development of temporary neurological dysfunction.

Effect of pleurotomy on blood loss during coronary artery bypass grafting.

BACKGROUND: We conducted a retrospective study to compare two different techniques of internal mammarian artery (IMA) preparation concerning pleurotomy upon the effects of blood loss and pulmonary functions. METHODS: Between January 1998 and November 2006, 1357 consecutive patients undergoing coronary artery bypass grafting (CABG) using the left IMA, either alone or in combination with saphenous vein graft, were included in this study. The patients were divided into two groups according to the pleural opening: Group I (n = 1046) patients underwent IMA harvesting with pleurotomy and Group 2 (n = 311) patients with intact pleura. RESULTS: During the study, 27 hospital deaths (1.9%) occurred. The amount of postoperative blood loss and blood transfusion requirements were significantly higher in Group 1 than in Group 2 (p = 0.029 and p = 0.0001). The mechanical ventilation stay was significantly higher in Group 1 than in Group 2 (p = 0.0001). The incidence of left pleural effusion and atelectasis was significantly higher in Group 1 than in Group 2 on day 1 and day 3 after operation. CONCLUSIONS: These results demonstrate that preserving pleural integrity has beneficial effects on the postoperative blood loss. Postoperative blood loss and transfusion requirements were higher in patients with pleurotomy. Left pleural effusion, atelectasis, and mechanical ventilatory stay were significantly reduced in patients with preserved pleural integrity.

Hydatid cyst confined to the papillary muscle: a very rare cause of mitral regurgitation.

Cardiac involvement of hydatid cysts is rare. Hydatidosis of the valvular apparatus can be treated successfully by the careful application of valvular surgical procedures. To the best of our knowledge, cardiac hydatidosis confined to the anterolateral papillary muscle has not been reported. Herein, we present a case involving a hydatid cyst that was located in a cardiac papillary muscle and that caused mitral regurgitation in a 37-year-old woman. The cyst was removed by papillary muscle incision, and the mitral valve was repaired. The patient experienced an uneventful recovery.

Surgical approaches to the aberrant right subclavian artery.

Aberrant subclavian artery (arteria lusoria) is a rare congenital anomaly that usually does not produce symptoms. Symptomatic patients require surgical intervention. The operative approach to correct this condition has been controversial. Herein, we describe surgical approaches to the aberrant right subclavian artery. From 2000 through 2004, 3 children and 1 adult with aberrant right subclavian artery underwent operation. Our surgical approach varied according to the age of the patient. A muscle-sparing right thoracotomy was used in the pediatric patients, and a supraclavicular approach was used in the adult. Patients were treated successfully by division of the aberrant right subclavian artery and translocation to the right common carotid artery, without graft interposition. There was no operative or late morbidity or death. Symptoms were completely relieved in all patients. Although an extrathoracic approach is applicable and reliable for adult patients, we believe that adequate exposure for the described procedure is best accomplished through a right thoracotomy in pediatric patients. This approach enables optimal mobilization of the distal right subclavian artery without leaving a long stump and enables direct anastomosis to the ipsilateral carotid artery.

Management of vascular infection in the groin.

We performed this retrospective study in order to evaluate the effectiveness of different surgical methods in the treatment of inguinal vascular infections. Fourteen consecutive patients underwent surgical treatment of such infections from 1996 through 2004 in our clinic. The mean age was 52 +/- 16 years. Seven of the 14 patients underwent emergency operation due to bleeding or acute ischemia. The events that caused inguinal infection were synthetic graft implantation in 8 patients, gunshot injury in 1, arterial catheterization in 2, femoropopliteal saphenous vein bypass operation in 1, and motor vehicle accident with abdominal wall laceration in 2. The most common infecting pathogen was Staphylococcus aureus (7 patients). Sixteen operations were performed in 14 patients. These operations included lateral femoral bypass (5), obturator bypass (5), revascularization with homograft (5), and femorofemoral bypass (1). All inguinal infections were completely cured after surgery. Early complications included poor wound healing (4 patients), minor amputation (1 patient), and extension of infection to the distal anastomosis of the obturator bypass and false aneurysm formation (1 patient). Late complications were acute homograft occlusion of a femorofemoral bypass and thrombosis of a below-knee lateral femoral bypass. There was no operative or late mortality. All patients were followed up for a mean of 48.1 +/- 21.9 months. We did not encounter any aneurysmal degeneration, rupture, or reinfection in homograft patients during follow-up. We conclude that vascular infections of the groin can be cured by proper selection and application of one of the above techniques.

Amiodarone reduces the incidence of atrial fibrillation after coronary artery bypass grafting.

OBJECTIVE: The purpose of this study was to evaluate the safety and efficacy of postoperative administration of prophylactic amiodarone in the prevention of new-onset postoperative atrial fibrillation in patients undergoing coronary artery bypass grafting. METHODS: In this prospective study 157 patients were randomly divided into two groups: 77 patients (amiodarone group) received intravenous amiodarone in a dose of 10 mg/kg/d for postoperative 48 hours. On postoperative day 2 oral amiodarone was started with a dose of 600 mg/d for 5 days, 400 mg/d for the following 5 days, and 200 mg/d for 20 days, and 80 patients received placebo (control group). RESULTS: Preoperative patient characteristics and operative variables were similar in the two groups. Postoperative atrial fibrillation occurred in 8 patients (10.4%) receiving amiodarone and in 20 (25.0%) patients receiving placebo (P =.017). Duration of atrial fibrillation was 12.8 +/- 4.8 hours for the amiodarone group compared with 34.7 +/- 28.7 hours for the control group (P =.003). The maximum ventricular rate during atrial fibrillation was slower in the amiodarone group than in the control group (105.9 +/- 19.1 beats per minute and 126.0 +/- 18.5 beats per minute, respectively, P =.016). The two groups had a similar incidence of complication other than rhythm disturbances (20.8% vs 20.0%, P =.904). Amiodarone group patients had shorter hospital stays than that of control group patients (6.8 +/- 1.7 days vs 7.8 +/- 2.9 days, P =.014). The in-hospital mortality was not different between two groups (1.3% vs 3.8, P =.620). CONCLUSIONS: Postoperative intravenous amiodarone, followed by oral amiodarone, appears to be effective in the prevention of new-onset postoperative atrial fibrillation. It also reduces ventricular rate and duration of atrial fibrillation after coronary artery bypass grafting. It is well tolerated and decreases the length of hospital stay.