Coronary bypass surgery in a 105-year-old patient with cardiopulmonary bypass.

Coronary artery bypass grafting is one of the routine daily surgical procedures in the current era. Parallel to the increasing life expectancy, cardiac surgery is commonly performed in octogenarians. However, literature consists of only seldom reports of coronary artery bypass grafting in patients above 90 years of age. In this report, we present our management strategy in a 105-year-old patient who underwent coronary artery bypass grafting at our institution.

Rhabdomyolysis following accidental intra-arterial injection of local anesthetic.

Drug-induced myopathy, also named Nicolau syndrome, is a well-known phenomenon following intramuscular injection of certain agents, most commonly reported with penicillin or diclofenac. The mechanism responsible for the pathology is proposed to be incidental administration of the drug into the small arterioles. In this report, we present a Nicolau syndrome-like case that developed following accidental injection of a local anesthetic agent into the femoral artery during coronary angiography.

Efficacy of remote ischaemic preconditioning for spinal cord protection against ischaemic injury: association with heat shock protein expression.

INTRODUCTION: We aimed to determine the efficacy of remote ischaemic preconditioning in the hind limb of rats for ischaemic damage of the spinal cord through neurological and histological investigation and examination of heat shock proteins (HSP). MATERIAL AND METHODS: Thirty male Sprague-Dawley rats were divided into three groups as Group 1 (control group, n=10), Group 2 (ischaemia control group, n=10), and Group 3 (remote ischaemia preconditioning group, n=10). The right lower limb of the rats in the study group was compressed with a tourniquet for three cycles of ten-minute ischaemia followed by ten-minute reperfusion. After a period of 8 hours, the peritoneal cavity was accessed through a midline vertical incision. The abdominal aorta was clamped between the origin of the renal arteries and the iliac arteries for 45 minutes and spinal cord ischaemia was induced. The same procedure of abdominal aorta clamping was performed in the control group without creating leg ischaemia. The rats were evaluated for neurological parameters at 24 and 48 hours. At the end of this time period, all rats were sacrificed and the spinal cords were stained for determination of HSP and histopathological classification. For immunohistochemical evaluation, the samples were analyzed according to the degree of staining with HSP70 rabbit antibody. RESULTS: After completing the neurological examinations and histological evaluations, we determined the spinal cords of the animals in the sham group to be completely normal. The post-operative neurological examination scores of Group 3 at 24 and 48 hours were significantly higher than scores measured in the other two groups. There were seven rats with HSP expression and this was detected in animals pretreated with remote ischaemic preconditioning. There were also two rats in Group 2 with HSP expression. CONCLUSION: Our results show that production of transient remote ischaemia preconditioning in the lower extremities reduces damage in the spinal cord secondary to ischaemia probably by the increase of HSP.

Papaverine solution improves preservation of saphenous vein grafts used during cardiac surgery.

The purpose of this study was to assess the viability and dilator response of the saphenous vein segments harvested during cardiac surgery. The saphenous veins were incubated with either normal saline (group A) or papaverine solutions (group B). The viability of saphenous vein endothelial cells was assessed by counting the number of total cells. Maximal endothelium-dependent vasodilator response to acetylcholine was also investigated. Cell viability of vein samples was decreased after 4 hours of incubation with normal saline (34 +/- 6.5%) as compared to solution containing papaverine (92 +/- 3.7%). By 24 hours, the viabilities of the endothelial cells incubated with saline and papaverine solutions were 22 +/- 4.5% and 87 +/- 5%, respectively.There was significant difference in vasodilatation responses to acetylcholine between saline-incubated and papaverine-incubated groups. By 4 hours of incubation, the relaxation response to acetylcholine significantly deteriorated in group A when compared to the initial value (P < 0.001). Furthermore, the decrease in this vasorelaxation response has also continued throughout the observation period and the values obtained by 24 hours were observed to be significantly lower than those obtained at the end of 4 hours (P < 0.01). In contrast, although a decrease was noticed in group B over time, this decrease was not statistically significant (P, not significant). We thus conclude that the use of papaverine solution improves endothelial cell viability and is associated with preservation of the maximal endothelial-dependent vasodilator response of a vein segment.

Effects of intrapleural analgesia on pulmonary function and postoperative pain in patients with chronic obstructive pulmonary disease undergoing coronary artery bypass graft surgery.

OBJECTIVE: Pain after coronary artery bypass graft (CABG) surgery remains a significant problem and may cause serious complications because of restricted breathing and limited early mobilization. The aim of this study was to assess the effects of intrapleural analgesia on the relief of postoperative pain in patients undergoing CABG surgery. DESIGN: Postoperative pain, pulmonary function tests, and outcomes were compared with a placebo group after CABG surgery in a double-blind randomized clinical trial. SETTINGS: Cardiovascular surgery clinic. PARTICIPANTS: One hundred twenty-five patients with decreased lung function were studied. INTERVENTIONS: Group A (62 patients) received 20 mL of 0.5% bupivacaine bilaterally in the intrapleural spaces every 6 hours for 4 days, and group B (63 placebo patients) received sterile saline solution. MEASUREMENTS AND MAIN RESULTS: Group A had a significantly shorter extubation time than the placebo group (8 +/- 1 h v 10 +/- 4 hours, p < 0.001). Blood gas analysis showed higher PaO2 and lower PaCO2 levels in group A. The patients receiving bupivicaine had significantly higher FEV1, FCV, VC, MVV, PEF, and FEF 25-75% values postoperatively when compared with the placebo group. Postoperative analgesic requirements and visual analog pain scales were significantly lower in group A. The intensive care unit stay in group A was shorter (1.2 +/- 0.7 v 1.4 +/- 0.6 days, p = 0.04); however, the hospital stay did not differ between groups. CONCLUSIONS: Improvement in lung function parameters correlating with decreased postoperative pain with intrapleural bupivacaine was observed. Intrapleural analgesia provided a good level of analgesia, improved respiratory performance, and allowed rapid mobilization, which led to a reduction of postoperative respiratory complications.

Being an elderly woman: is it a risk factor for morbidity after coronary artery bypass surgery?

OBJECTIVE: Despite the refinements in surgical techniques and postoperative care, elderly women still have a higher prevalence of postoperative morbidity. METHODS: The outcomes of 112 elderly women (>80 years) who underwent an elective CABG procedure were compared with those of males operated during the same time interval (n, 164). RESULTS: Median age of female and male patients were 82 and 83 years, respectively. Mean number of grafts did not differ significantly (3.7+/-0.8 vs 3.9+/-0.3, p=0.4) between groups. Overall early operative mortality rate was 8.6% (24 of 276 patients); 8.9% (10 of 112 patients) for female and 8.5% (14 of 164 patients) for male patients (p=0.1). Postoperative complications including prolonged ventilation time (13.4% in females vs 8.5% in male, p<0.01), atrial fibrillation (40% in females vs 33% in males, p=0.01), sternal reclosure (8% in females vs 4.2% in males, p=0.01), pneumonia (5.3% in females vs 3% in males, p=0.03), leg wound infection (11.7% in females vs 2.4% in males, p<0.001), renal dysfunction (10.7% in females vs 7.3% in young patients, p=0.02) have been found to be significantly higher in elderly women. Mean intensive care unit (3.2+/-1.1 days in females vs 1.6+/-0.4 in males, p=0.03), and hospital stays (13.6+/-2.1 days in females vs 9.1+/-1.2 in males, p=0.02) were also longer in female patients. Five-year survivals including all deaths for female and male patients were 57% and 62%, respectively. CONCLUSIONS: In elderly women, revascularization procedures can be done with acceptable mortality rates; but these patients are still associated with a higher prevalence of postoperative morbidity when compared with the male counterparts. Therefore, these patients have to be very carefully evaluated preoperatively and their postoperative care should be more comprehensive to reduce the incidence of postoperative complications.

Long-term results of the left anterior descending coronary artery reconstruction with left internal thoracic artery.

BACKGROUND: Recent refinements in percutaneous techniques have resulted in an increase in the numbers of patients with diffuse coronary artery disease who are referred to cardiac surgeons. Long-segmental reconstruction of the diffusely diseased left anterior descending (LAD) coronary artery with the left internal thoracic artery (LITA) has been shown to be beneficial for patients with diffuse coronary artery disease. In this retrospective study, we analyzed the long-term outcomes obtained with this technique. METHODS: Between April 1997 and February 2006, 3736 coronary artery bypass grafting (CABG) operations were performed by our team. Of these cases, 524 patients (14%) with the diffusely diseased LAD underwent a long-segmental reconstruction procedure with a LITA graft. RESULTS: The cohort consisted of 372 men (71%) and 152 women (29%), and the mean age was 56.5 +/- 8.2 years. The mean length of the arteriotomy incision was 4.5 +/- 1.2 cm (range, 2 to 10 cm). Postoperative mortality was 1.9%, and the myocardial infarction rate was 6.9%. At 3, 5, and 7 years, overall survival was 93.8% +/- 0.5%, 89.6% +/- 1.5%, and 85.5% +/- 2.6%, and actuarial freedom from angina recurrence was 94.5% +/- 1%, 88.5% +/- 2%, and 82.9% +/- 3%, respectively. Among survivors, interim angiographic evaluation was performed in 128 patients at a mean follow-up of 52.4 +/- 13.5 months, and the patency rate of the LITA-LAD anastomosis was 91.4%. CONCLUSIONS: Patients with diffuse LAD disease present a major challenge for cardiovascular surgeons. The long-term results of long-segmental LAD reconstruction are very encouraging, and this approach may be used safely in this subgroup of patients.

CABG without using heparin in a patient with heparin-induced thrombocytopenia.

BACKGROUND: Despite the low incidence of heparin-induced thrombocytopenia and thrombosis, these two syndromes are much disputed in life-threatening conditions especially in cardiovascular surgery where heparin is routinely used. Nowadays a pharmacological agent that can exactly replace heparin does not exist. Many of the drugs called "alternative drugs to heparin" are associated with a high risk of hemorrhagic complications and an increased need of blood transfusions. Neither the use of heparin nor "alternative drugs to heparin" may be the best way to revascularize a patient with heparin-induced thrombocytopenia. METHODS: Coronary artery bypass grafting without using heparin was performed in a 62-year-old male patient with heparin-induced thrombocytopenia. He received clopidogrel and acethyl salicylic acid for 2 days before operation. He was operated off-pump using special maneuvers. RESULTS: He was discharged on postoperative day 5 after an uneventful course and is doing well in the sixth month postoperatively. CONCLUSIONS: According to our investigations in English literature, this surgical technique and coronary artery bypass grafting without using heparin is firstly described in this article. Increasing the number of cases will show the reliability and safety of this method.