Which Mechanism is Effective on the Hyperamylasaemia After Coronary Artery Bypass Surgery?

BACKGROUND AND AIM: Acute pancreatitis is one of the less frequently diagnosed lethal abdominal complications of cardiac surgery. The incidence of early postoperative period hyperamylasaemia was reported to be 30-70% of patients who underwent coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB). The mechanism of pancreatic enzyme elevation after cardiac surgery is not clear. Our aim was to determine the relationship between ischaemia associated temporary renal dysfunction and elevation of pancreatic enzymes after CABG. METHODS: Forty-one consecutive patients undergoing CABG under CPB were prospectively studied to determine serum total amylase, phospholipase A2, macroamylase, Cystatin C and urine NAG levels. RESULTS: Hyperamylasaemia was observed in 88% of the cases, with a distribution of 6% at the beginning of cardioplegic arrest, 5% at the 20th minute after cardioplegic arrest, 7% at the 40th minute after cardioplegic arrest, 14% when the heart was re-started, 26% at the 6th hour of intensive care and 30% at the 24th hour of intensive care. All of these patients had asymptomatic isolated hyperamylasaemia, and none of them presented with clinical pancreatitis. As indicators of renal damage; Cystatin C and NAG levels were higher compared to baseline values. CONCLUSION: Amylase began to rise during initial extracorporeal circulation and reached a maximum level postoperatively at 6 and 24hours. Decreased amylase excretion is the main reason for post CABG hyperamylasaemia.

Five-year follow up of Konno aortoventriculoplasty for repeat aortic valve replacement in an adult patient.

Konno aortoventriculoplasty (AVP) is performed for various types of left ventricular outflow tract obstruction. We report on a 32-year-old woman who had undergone double valve replacement five years earlier. She presented with increased interventricular septum thickness, small aortic root and gradient across the aortic mechanical valve. We performed Konno AVP with repeat aortic valve replacement (AVR). The control echocardiography showed no significant residual gradient. Konno AVP with repeat AVR may be safely performed with satisfactory results.

Investigation of the direct hepatic effects of intramuscular interleukin-8 injection in an experimental rabbit model.

BACKGROUND: The aim of this study was to investigate the effects of intramuscular IL-8 injection on hepatic tissues using an in vivo histopathological animal model. MATERIAL AND METHODS: Twelve New Zealand white rabbits were used for this randomized, controlled, single-blinded interventional study. For 6 days, 1 gluteus maximus muscle was injected daily with 1 mcg/kg of IL-8 in 6 rabbits (Group A). The remaining 6 rabbits (to determine to normal porto-hepatic morphology of the rabbit genus) were in the sham group (Group B). At the end of the 7th day, all rabbits were killed and livers were meticulously harvested. Microscopically, regional tissues were scored according to portal inflammation, focal necrosis, piecemeal necrosis, and total impact. RESULTS: Total impact score, portal inflammation, focal necrosis, and piecemeal necrosis were the histopathologic changes present in a higher incidence in the IL-8 group compared with the control group. The differences were significant when the groups were compared according to total impact score, portal inflammation, focal necrosis, and piecemeal necrosis according to Pearson's correlation (p<0.05). The most significant differences were detected at the total impact scores (p=0.002) and the portal inflammation scores (p=0.008). CONCLUSIONS: Our results showed that IL-8 may damage hepatocytes. This can be the determined target for new therapeutic strategies. Further trials should be designed to obtain definitive results.

Which is first: left anterior descending artery anastomosis or right coronary artery anastomosis in off-pump coronary artery bypass grafting?

OBJECTIVES: The sequence of the distal anastomosis for revascularization in off-pump coronary artery bypass grafting (OPCABG) surgery is under debate. The hypothesis in this study was that an analysis of cardiac markers would reveal that anastomosing the left anterior descending coronary artery (LAD) before the right coronary artery (RCA) would decrease myocardial damage in OPCABG surgery for 2-vessel disease. METHODS: Forty patients with stable angina who underwent OPCABG surgery and who had LAD and RCA lesions were randomized into 2 groups of 20 patients each. The LAD was revascularized first in group 1, and the RCA was revascularized first in group 2. Cardiac troponin I, creatine kinase (CK), and CK myocardial band (CK-MB) were measured in the 2 groups before surgery and at 8, 24, and 48 hours after surgery. RESULTS: No mortality occurred in the 2 groups. The groups were similar with respect to sex, age, durations of anastomosis of the left internal thoracic artery to the LAD and of the saphenous vein graft to the RCA, and preoperative CK, CK-MB, and troponin I levels. Postoperative CK-MB levels were significantly higher in group 2 in the eighth and 24th postoperative hours than in group 1 (P = .009 and .041, respectively). Similarly, troponin I levels were significantly higher in group 2 in the eighth, 24th, and 48th hours than in group 1 (P = .003, .003, and .006, respectively). CONCLUSIONS: Anastomosis to the LAD first in OPCABG surgery led to a slight reduction in myocardial enzyme release against the occlusion of the target vessels during anastomoses in patients with RCA and LAD stenoses.

Iloprost and pentoxifylline attenuate ischemia-reperfusion injury in skeletal muscle in rabbit model.

BACKGROUND: We investigated the effects of iloprost and pentoxifylline on skeletal muscle ischemia-reperfusion injury in a rabbit model. METHODS: Forty New Zealand white rabbits were grouped into four. In Group 1, iloprost was continuously infused starting half an hour before the reperfusion following a 2-hour ischemia formed by abdominal aortic occlusion, and it was continued during the 4-hour reperfusion period. Group 2 was treated with pentoxifylline, and Group 3 received saline solution. Group 4 was the sham group. Malondialdehyde levels and edema scores in gastrocnemius muscle were evaluated. RESULTS: Edema score was significantly lower in Group 1 when compared with the control group (Group 1 vs Group 3, p=0.040; Group 2 vs Group 3, p=0.145; Group 1 vs Group 2, p=0.580). Malondialdehyde levels of the medicated groups were significantly lower when compared with the control group (Group 1: 60+/-11 nmol/g tissue, Group 2: 74+/-11 nmol/g tissue, Group 3: 95+/-10 nmol/g tissue; Group 1 vs Group 2, p=0.010; Group 1 vs Group 3, p<0.001; Group 2 vs Group 3, p<0.001; Group 1 vs Group 4, p<0.001; Group 2 vs Group 4, p<0.001; Group 3 vs Group 4: p<0.001). CONCLUSION: Acute skeletal muscle ischemia is a common problem. We are of the opinion that in the early phase of skeletal muscle ischemia, iloprost and pentoxifylline medication may reduce ischemia-reperfusion injury.

A simple and effective technique for left ventricular deairing.

OBJECTIVE: Despite careful deairing procedures, residual air has been found in the left ventricle. For this reason, we created a simple and effective left ventricular deairing technique. DESIGN: Forty patients with pure mitral valve disease were randomly divided into 2 groups. In group 1, deairing was done by filling the left atrium actively by a line coming from the aortic cannula line, and by venting from the antegrade cardioplegia line. In group 2, the air was removed by ventilating the lungs, and venting from the antegrade cardioplegia line, but not active filling of the left atrium. The patients were evaluated with transesophageal echocardiograpy during the procedure. RESULTS: According to the preoperative data, the groups were similar. After 3 minutes of deairing, 5 patients in group 2 had transesophageal echocardiographical air bubbles. In these patients, after 2 minutes, the air was removed by an active filling technique. None of the patients in group 1 had air bubbles. DISCUSSION: The technique described in this study seems to solve remaining air problems in the cardiac chambers. It can be applied easily, and it is safe and effective.

The influence of levosimendan and iloprost on renal ischemia-reperfusion: an experimental study.

The effects of iloprost on ischemia-reperfusion injury have been studied on the skeletal, muscle, liver, myocardium, kidney, and spinal cord. However, no sufficient data exist about effects of levosimendan on renal ischemia-reperfusion injury. The purpose of this experimental study was to investigate and compare effectiveness of levosimendan and iloprost on renal injury induced by ischemia and reperfusion. Fifty rabbits were divided into five groups. Levosimendan was continuously infused starting half an hour before the cross-clamp. Cross-clamp time was one hour. After one hour ischemia, levosimendan was continued for 4 h in Group A whereas Group B took iloprost in the same protocol. Group C was the control group which did not receive any medication. Group D was sham group and Group E was medicated both iloprost and levosimendan. Renal tissues were histologically and biochemically evaluated. The histological scores were obtained according to presence of tubular necrosis and atrophy, regenerative atypia, hydropic degeneration (Group A vs. Group C<0.001, Group B vs. Group C<0.001, Group D vs. Group C<0.01, Group E vs. Group C<0.001). Mean malondialdehyde levels were 114+/-12 nmol/g tissue; in Group A 121+/-13 nmol/g tissue, in Group B 134+/-13 nmol/g tissue, in Group E 130+/-11 nmol/g tissue, in Group D 134+/-11 nmol/g tissue (Group A vs. Group B; P=0.003, Group B vs. Group D; P=0.132, Group A vs. Group E; P=0.132). Malondialdehyde levels and histologic scores of all of the groups were significantly different from the control group. Iloprost and pentoxyfillin reduced renal ischemia-reperfusion injury in rabbit model. There was no significant difference between these two medications.

Inferior mesenteric artery aneurysm combined with renal artery stenosis in a patient with neurofibromatosis.

A case is reported of an inferior mesenteric artery aneurysm that starts approximately 1 cm from its origin and ends at the proximal portion of the bifurcation of the sigmoidal and left colic arteries accompanied with complete absence of the celiac axis and superior mesenteric arteries. Additionally, left renal artery stenosis existed. The diagnosis was made by digital subtraction arteriography and confirmed by magnetic resonance arteriogram. Disease involving the inferior mesenteric artery is extremely uncommon. This may be the first reported case of neurofibromatosis in combination with renal artery stenosis and inferior mesenteric artery aneurysm associated with celiac and superior mesenteric artery occlusion and treated surgically.

Perfusion pressure does not affect neurologic outcome in axillary artery side graft cannulation in type a aortic dissection.

OBJECTIVE: Antegrade selective cerebral perfusion (ASCP) through the right axillary is a safe and effective method for cerebral protection in aortic surgery. In the present study, we evaluated whether or not pressure control in ASCP affected the neurologic outcome. METHOD: Sixty-two patients (17 female, 45 male) with a mean age of 53.9 +/- 9.4 years (range, 23-74 years) with a diagnosis of Type A aortic dissection were operated on by using the right axillary artery side graft cannulation technique. ASCP with pressure control was used in the first 37 (59.6%) patients (group 1), whereas ASCP with flow control was used in the consecutive 25 patients (39.4%) (group 2). The groups were compared according to postoperative neurologic outcomes. RESULTS: The hospital mortality rate was 9.7% with 6 patients. The mean ASCP flows of group 1 was 663 +/- 76 mL/min and 692 +/- 51 mL/min in group 2. This difference was not statistically significant (P = .120). The neurological dysfunction rates were 2.7% in group 1 with 1 patient and 8% in group 2 with 2 patients (P = .560). CONCLUSION: In this study, we could not find a statistically significant difference in patients treated with ASCP through the right axillary applicated with pressure control versus flow control.

Whole-body perfusion under moderate-degree hypothermia during aortic arch repair.

INTRODUCTION: There continue to be some controversies concerning aortic arch reconstruction, especially the cerebral protection methods. We report our operative and postoperative outcomes for cases of aortic arch replacement using whole-body perfusion during aortic reconstruction under 28 degrees C moderate hypothermia. MATERIALS AND METHODS: A total of 12 patients were operated on between March 2003 and November 2005. Two of the patients were female. The mean age of the patients was 53.5 x 7.3 years (range, 42-65 years). We cannulated the right axillary artery for cerebral perfusion and the right femoral artery for body perfusion. Arch replacement was done under continuous antegrade cerebral perfusion through the right axillary artery and continuous body perfusion through the right femoral artery via intra-aortic occlusion of the proximal descending aorta with an intra-aortic occlusion catheter. Perioperative data and postoperative outcomes, blood urea nitrogen, serum creatinine, and alanin aminotransferase values were evaluated retrospectively in the patients. RESULTS: There was only 1 hospital mortality. There were no neurologic complications. Postoperative levels of blood urea nitrogen and creatinin did not show significant difference but the alanin aminotransferase levels were significantly higher in the postoperative period, which was within the normal ranges of cardiopulmonary bypass effect. DISCUSSION: Whole-body perfusion through the axillary and femoral arteries may provide more time for the surgeon and good cerebral and visceral protection, which are especially important for surgical teams in the learning curve.