Factors associated with increased intra-abdominal pressure in patients undergoing cardiac surgery.

BACKGROUND: The aim of this study was to investigate the intra-abdominal pressure changes and risk factors associated with increased intra-abdominal pressure in patients undergoing cardiac surgery. METHODS: Between July 2016 and January 2017, a total of 100 patients (74 males, 26 females; mean age 55.9±14.3 years; range, 19 to 75 years) who underwent cardiac surgery under cardiopulmonary bypass were included in the study. Patients" data including demographic and clinical characteristics and intra- and postoperative data were recorded. Intra-abdominal pressure was measured via a urinary catheter after anesthesia induction, on admission to the intensive care unit, and at postoperative 12 and 24 h. The patients were divided into two groups according to the intraabdominal pressure as Group 1 (≥12 mmHg; n=49) and Group 2 (<12 mmHg; n=51). RESULTS: In the univariate regression analysis, high intra-abdominal pressure was related to intra-abdominal pressure measured after anesthesia induction (Odds Ratio =0.70, p=0.001), age (odds ratio=0.95, p=0.004), hypertension (odds ratio=4.51, p=0.0001), duration of cardiopulmonary bypass (odds ratio=0.97, p=0.0001), intraoperative lactate levels (odds ratio=0.53, p=0.0001), use of red blood cells (odds ratio=0.24, p=0.0001), use of dopamine (odds ratio=0.21, p=0.002), dobutamine (odds ratio=0.28, p=0.005), use of noradrenaline (odds ratio=0.25, p=0.016), postoperative lactate levels (odds ratio=0.60, p=0.0001), duration of cross-clamp (odds ratio=0.97, p=0.0001), atrial fibrillation (odds ratio=5.89, p=0.004), and acute kidney injury (odds ratio=8.33, p=0.048). In the multivariate analysis, the intra-abdominal pressure at baseline (odds ratio=0.70, p=0.045), age (odds ratio=0.93, p=0.032), hypertension (odds ratio=6.87, p=0.023), duration of cardiopulmonary bypass (odds ratio=0.98, p=0.062), intraoperative lactate levels (odds ratio=0.57, p=0.035), and use of red blood cells (odds ratio=0.19, p=0.003) remained statistically significant. CONCLUSION: Our study results suggest that age, hypertension, duration of cardiopulmonary bypass, intraoperative lactate levels, and use of red blood cells are risk factors associated with elevated intra-abdominal pressure in patients undergoing cardiac surgery. Increased awareness of these risk factors and the addition of intra-abdominal pressure measurement to the standard follow-up scheme in patients with variable hemodynamics, low cardiac output, and high lactate levels in the intensive care unit may be useful in early diagnosis of complications and in decreasing morbidity.

A retrospective analysis of factors influencing re-operation in patients undergoing mechanical valve replacement.

BACKGROUND: We aimed to determine the possible factors leading to re-operation in patients undergoing mechanical valve replacement and to investigate the relationship between valvular thrombus formation and mean platelet volume. METHODS: The medical records of 43 patients with mechanical valve implantation, who were admitted to the Department of Cardiovascular Surgery of Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital between 2000 and 2005 were analysed retrospectively. Data recorded included demographic characteristics, valve type, size and location, implantation position, warfarin use, INR level, additional cardiac intervention, presence of left atrial thrombus, valvular thrombus, pannus formation, perivalvular leak, left atrial aneurysm, platelet count and mean platelet volume (MPV), bleeding after the primary surgery and/or revision of surgery due to other reasons, valve protection, aortic root expansion, presence of valve calcification and infective endocarditis, pre- and postoperative rhythm pattern, brand name of prosthesis, distance of the patient's house from a cardiac surgery centre, and concomitant noncardiac systemic diseases. RESULTS: Mean age was 49.3 years (range 19-78 years). Of the patients, 51% (n = 22) were males and 49% (n = 21) were females. The re-operation mortality was 11.6%. Age, gender, valve type, brand of valve prosthesis, and implantation position were not risk factors for re-operation. The MPV was higher and statistically significant in patients with valvular thrombus during re-operation (p < 0.001). MPV was determined to be an independent risk factor with 85% sensitivity and 87% specificity. CONCLUSION: MPV and INR levels should be closely monitored when designing individualised postoperative medical treatment for patients undergoing heart valve re-operation.

Comparison between local and general anesthesia for carotid endarterectomy: early and late results.

BACKGROUND: The aim of this retrospective study was to compare the results between general and local anesthesia (LA) for carotid endarterectomy (CEA). METHODS: Three hundred and twenty-nine patients in whom 365 CEA procedures were performed between January 1990 and September 2001, were included in this study. RESULTS: Operation time, shunt usage rates, hospitalization time (P < .0001), and permanent stroke rates (P < .05) were significantly lower in group with LA. For long-term period (121.3 ± 37.45 vs 98.6 ± 28.98 months), no significant difference was observed in these 2 group with respect to restenosis rates, neurological events, and deaths. CONCLUSIONS: Despite the lack of significant difference between LA and general anesthesia in terms of restenosis, neurological events, and death in the long-term period; LA is more preferable due its associated advantages including availability of testing the consciousness of the patients by direct contact, reduced use of shunts, shorter hospitalization periods, and less prevalence of permanent stroke in the short-term period.

Dexmedetomidine in cardiac surgery patients who fail extubation and present with a delirium state.

BACKGROUND: We evaluated the use of dexmedetomidine to facilitate the weaning of delirious postoperative patients from mechanical ventilation. METHODS: We included 72 consecutive patients who underwent elective cardiac surgery in this prospective observational study. Each patient had failed at least 1 trial of continuous positive airway pressure (CPAP) and had agitation. Patients were assessed with the Richmond Agitation-Sedation Scale (RASS) and the Confusion Assessment Method for the Intensive Care Unit (CAMICU) 12 to 18 hours after their admission to the ICU. Midazolam and fentanyl were then given to all patients according to the sedation protocol. At 36 hours in the ICU, patients who had agitation and an inability to wean were randomly divided into 2 groups: group M, 34 patients who continued to follow the routine sedative protocol; and group D, 38 patients who were given dexmedetomidine. Arterial blood gas measurements, hemodynamic parameters, and time to extubation were recorded. Statistical analysis was performed with GraphPad InStat (version 2.02 for DOS). RESULTS: All patients tested positive in the CAM-ICU assessment, and all had a delirium diagnosis. The 38 patients in group D tolerated a spontaneous breathing trial with CPAP and were extubated after a mean (±SD) of 49.619 ± 6.96 hours. The 2 groups had significantly different extubation times (58.389 ± 3.958 hours versus 49.619 ± 6.96 hours). The 2 groups had significantly different RASS scores at 48 and 60 hours and significantly different heart rates and PO2 values at 12 and 24 hours. The 2 groups showed no significant differences with regard to hemodynamic parameters. CONCLUSIONS: Dexmedetomidine may help to eliminate the emergence of agitation and can be a good treatment choice for the delirium state after cardiac surgery.

Results of treatment methods in cardiac arrest following coronary artery bypass grafting.

BACKGROUND AND AIM OF THE STUDY: Emergency re-revascularization and invasive/noninvasive interventions in intensive care unit (ICU) are two main treatment methods in cardiac arrest following coronary artery bypass grafting (CABG). We evaluated the short- and long-term consequences of these two methods and discussed the indications for re-revascularization. METHODS: Between 1998 and 2004, a total of 148 CABG patients, who were complicated with cardiac arrest, were treated with emergency re-revascularization (n = 36, group R) and ICU procedures (n = 112, group ICU). Re-revascularizations are mostly blind operations depending on clinical/hemodynamic criteria. These are: no response to resuscitation, recurrent tachycardia/fibrillation, and severe hemodynamic instability after resuscitation. Re-angiography could only be performed in 3.3% of the patients. Event-free survival of the groups was calculated by the Kaplan-Meier method. Events are: death, recurrent angina, myocardial infarction, functional capacity, and reintervention. RESULTS: Seventy percent of patients, who were complicated with cardiac arrest, had perioperative myocardial infarction (PMI). This rate was significantly higher in group R (p = 0.013). The major finding in group R was graft occlusion (91.6%). During in-hospital period, no difference was observed in mortality rates between the two groups. However, hemodynamic stabilization time (p = 0.012), duration of hospitalization (p = 0.00006), and mechanical support use (p = 0.003) significantly decreased by re-revascularization. During the mean 37.1 +/- 25.1 months of follow-up period, long-term mortality (p = 0.03) and event-free survival (p = 0.029) rates were significantly in favor of group R. CONCLUSION: Better short- and long-term results were observed in the re-revascularization group.

Simultaneous open-heart surgery and pectus deformity correction.

PURPOSE: Pectus deformities and cardiac problems sometimes require simultaneous surgery. We report our experience of performing this surgery and review the relevant literature. METHODS: We performed simultaneous pectus deformity correction and open-heart surgery in six patients between 1999 and 2006. The pectus deformities were pectus carinatum in one patient and pectus excavatum in five patients. The cardiac problems were coronary artery disease in one patient, an atrioseptal defect (ASD) with a ventricular septal defect (VSD) in one, a VSD in one, mitral valve insufficiency with left atrial dilatation in one, and an ascending aortic aneurysm with aortic valve insufficiency caused by Marfan's syndrome in two. We corrected the pectus deformities using the modified Ravitch's sternoplasty in all patients. First, while the patient was supine, we resected the costal cartilage; then, after completing the cardiac surgery, the sternum was closed and the additional time required for the pectus operation was calculated for each patient. Patients were examined 1, 4, and 6 months postoperatively. RESULTS: The average operation time was 102 min, and there were no major complications. The pectus bars were removed 4-6 months postoperatively. Good cardiac and cosmetic results were achieved in all patients, who were followed up for 5 years. CONCLUSIONS: Concomitant pectus deformity correction and open-heart surgery can be performed safely, eliminating the risks of a second operation in a staged procedure.

Role of physiological state 'normothermia' in internal thoracic artery spasm after harvesting.

OBJECTIVE: Vasospasm is often faced after the operative preparation of internal thoracic artery. Different vasodilating pharmacological agents are being used to eliminate this problem. During the preparation of internal thoracic artery, normal, local, and systemic temperatures are lost. We aimed to find out the effect of this decrease in temperature on the free flow of internal thoracic artery. METHODS: We investigated the effects of normal saline solution at 20 degrees C (group I), papaverine at 20 degrees C (group II) and normal saline solution at 37 degrees C (group III). Each group contained 20 patients undergoing coronary bypass. Free flow of the left internal thoracic artery was measured after mobilization. After approximately 18 min the graft had been sprayed with one of the agents, and the second free flow was measured (t-interval was 18.2+/-2.1 for group I, 18.3+/-1.8 for group II, and 17.5+/-1.9 for group III). RESULTS: Normal saline solution at 20 degrees C did not cause a significant change. Topical papaverine at 20 degrees C increased the flow from 42.1+/-10.7 ml/min to 77.5+/-17.9 ml/min (p < 0.0001). A significant increase also occurred with normal saline solution at 37 degrees C from 41+/-11.9 ml/min to 75.3+/-18.9 ml/min (p < 0.0001). CONCLUSIONS: After harvesting the graft, regaining physiological normothermic state is enough for vasodilatation. Even using one of the most potent vasodilating agent papaverine at 20 degrees C is not superior to normothermia.

Efficacy of physiologic temperature on the spasm of harvested radial artery.

BACKGROUND: The potential disadvantage of using the radial artery for coronary artery bypass grafting is its increased tendency to vasospasm. Therefore, different antispastic agents are being used in the perioperative and postoperative period. During the preparation of the radial artery, normal local and systemic temperatures are lost. METHODS: We investigated the effects of topical normal saline solution at 20 degrees C (group SI), normal saline solution at 36 degrees C (group SII), diltiazem at 20 degrees C (group DI), and diltiazem at 36 degrees C (group DII) on radial artery free flow. Each group contained 10 patients undergoing coronary bypass surgery. Free flow and local temperature were measured at 3 stages: after the exploration and preparation of the distal 3 cm of the radial artery, after total preparation of the radial artery, and a median of 12 minutes after the pedicle had been sprayed with one of the agents. RESULTS: Parallel to the significant decrease of the second local temperatures (P < .001), the second flow of the 4 groups decreased significantly (P < .001). CONCLUSION: Hypothermia plays an important role in radial artery vasospasm, and normothermia may be the best perioperative vasodilating agent since the normal radial artery flows were reached with normothermia.

Detection of Chlamydia pneumoniae and Helicobacter pylori in atherosclerotic plaques of carotid artery by polymerase chain reaction.

OBJECTIVES: A possible role of some microorganisms has been proposed in the pathogenesis of atherosclerosis, but it is still an unresolved issue. We investigated the presence of Chlamydia pneumoniae and Helicobacter pylori DNA in carotid artery atherosclerotic plaques by using PCR. METHODS: One hundred and four patients with atherosclerotic diseases were included. The study group consisted of 52 atherosclerotic plaque specimens obtained from the carotid arteries of patients who had carotid endarterectomy and the control group consisted of 52 specimens obtained from the macroscopically healthy regions of ascending aorta in patients who had undergone coronary artery bypass grafting. The presence of C. pneumoniae and H. pylori DNA in endarterectomy specimens were demonstrated by PCR. RESULTS: C. pneumoniae DNA was detected in 16 of 52 (30.8%) atherosclerotic plaques and 1 of 52 (1.9%) macroscopically healthy ascending aorta wall specimens (P < 0.001). H. pylori DNA was detected in 9 of 52 (17.3%) atherosclerotic plaques and none of the controls (P = 0.003). CONCLUSIONS: The higher incidence of C. pneumoniae and H. pylori DNA in atherosclerotic plaques suggests that these microorganisms may play a role in the pathogenesis of atherogenesis.

Tricuspid valve perforation by permanent pacemaker lead--a case report.

Tricuspid valve perforation with pacemaker lead is one of the extremely rare complications of transvenous pacemaker implantation. Approximately all reported cases have been diagnosed at autopsy. The authors present a case of tricuspid valve perforation caused by pacemaker lead that was diagnosed during cardiac surgery and treated successfully by removing the lead and suturing the tricuspid valve.

Spontaneous pseudoaneurysm of the vertebral artery in Behçet's disease.

A pulsatile mass and severe neck pain developed suddenly in a 15-year-old female patient suffering from Behçet's disease. Magnetic resonance imaging showed a pseudoaneurysm at the C3-C4 level that was 51 x 49 x 45 mm in size, originating from the left vertebral artery, with a thin neck and thrombus inside. Repair of the vertebral artery wall by percutaneous transluminal intervention was not successful. Because of the possibility of rupture, the patient underwent surgical repair. Ligation of the left vertebral artery was applied 1 cm above the origin of the subclavian artery. During the subsequent postoperative period, no further complications were seen. From our review of the literature, this is the first reported case of surgical treatment of spontaneous development of a pseudoaneurysm at the vertebral artery in association with Behçet's disease. Ligation of the vertebral artery can be safely used to control a pseudoaneurysm related to Behçet's disease.

Effects of direct stent implantation and conventional stent implantation on minor myocardial injury.

Direct coronary stenting without balloon predilation has the potential benefits of a reduced risk of extended dissections, reduced fluoroscopy exposure, reduced procedural time, and potential cost savings. The purpose of the study was to compare the effects of angiographically successful direct stent implantation and conventional stent implantation (stent implantation following predilation) on minor myocardial injury characterized by cardiac troponin I (cTn-I), and cardiac troponin T (cTn-T) elevation. The authors prospectively studied 42 patients who had successful direct stent implantation, and 49 patients who had successful conventional stent implantation. Blood samples for measurement of cTn-I and cTn-T were taken before, and immediately after the procedure, and every 6 hours for the first 24 hours. cTn-T elevation was observed in 6 patients (14.3%) in the direct stent implantation group, and in 16 patients (32.6%) in the conventional stent implantation group (p: 0.03). Similarly cTn-I elevation was more frequent in the conventional stent implantation group (20 patients, 40.8%) than direct stent implantation group (7 patients, 16.7%, p: 0.02). Stent implantation following predilation is more frequently associated with postprocedural minor myocardial injury than direct stent implantation.

Local versus general anesthesia for carotid endarterectomy: report of 329 cases.

Since stroke is an important cause of morbidity and mortality, carotid endarterectomies are used frequently to reduce the risk of stroke and death. Unfortunately, an inherent risk of the carotid endarterectomy procedure is that surgery itself may result in stroke. At this point the question is which method of anesthesia, local or general, is better to protect and monitorize the brain function during cross-clamp period in carotid endarterectomies? In the authors' center, 365 carotid endarterectomies were applied to 329 patients between 1990 and 2001; 165 operations were done under general anesthesia and the other 200 operations were done under local anesthesia. These 2 groups, general (group I) and local anesthesia (group II), were studied retrospectively according to preoperative and postoperative data. In group I, the rate of major stroke was 7.3%, but this rate was 1% in group II (p < 0.05). Intraoperative shunts were used in 50 (30.3%) operations of group I, but the usage of shunt was 8% (16 operations) in group II (p < 0.0001). The hospitalization period was also much shorter in group II than in group I. The time of hospitalization was 4.1 +/-1.9 days in group I and 2.4 +/-1.1 days in group II (p < 0.0001). In terms of cost analysis, the mean costs were 1007.14 dollars +/-135.71 dollars in group I and 885.71 dollars +/-78.57 dollars in group II (p < 0.0001). In short, the local procedure was more cost-effective. As a result, in carotid endarterectomy procedures, the authors prefer local anesthesia to achieve better brain function monitoring and to reduce hospitalization time and cost.

The relationship between the method of cardioplegia and vascular endothelial cell derived soluble adhesion molecules in myocardial ischemia-reperfusion injury.

The relative role of different adhesion molecules in the ischemia-reperfusion injury after cardioplegic arrest in the clinical setting is unknown, because of protective effects of cardioplegia and hypothermia. The aim of this study is to determine the relationship between the method of the cardioplegia and endothelial derived soluble adhesion molecules; soluble vascular adhesion molecule-1 (sVCAM-1) and soluble intercellular adhesion molecule-1 (sICAM-1) in myocardial ischemia- reperfusion injury. Fourteen male patients who underwent aortocoronary bypass surgery with cardiopulmonary bypass were included in this study. They were randomised to be given blood or crystalloid cardioplegia for myocardial protection. Group I (n=7) received blood cardioplegia and group II (n=7) received crystalloid cardioplegia. The cross-clamp times were not significantly different between the two groups, 49.4+/-4.6 min for group I and 54.8+/-2.5 min for group II. Mean age of patients was 58+/-2.1 years for group I and 54+/-2.6 years for group II. Blood samples were taken from both the aorta and coronary sinuses of all patients before cross-clamp, after cross-clamping and at 30th min of reperfusion. Plasma were obtained from blood samples and then stored at -70 degrees C. sVCAM-1 and sICAM-1 levels were measured by ELISA in the samples. There were no significant differences in the levels of sICAM-1 and sVCAM-1 at the beginning of reperfusion and at 30th min of reperfusion in coronary sinus of group I patients. But, increased sICAM-1 and sVCAM-1 levels were observed at 30th min of reperfusion in blood taken from coronary sinuses of group II patients compared with beginning of reperfusion (respectively p=0.01, p=0.03). In conclusion, these results have shown that ischemia-reperfusion injury is more likely to occur in patients protected by crystalloid cardioplegia, and suggest that blood cardioplegia may be preferred especially in borderline myocardial functioned patients.

Limb ischemia due to use of internal thoracic artery in coronary bypass.

Immediately after undergoing coronary bypass grafting using the left internal thoracic artery, a 59-year-old man developed left leg ischemia. Right-to-left femoral artery crossover bypass was performed and the ischemia resolved. A 72-year-old man developed left calf pain 12 days after a similar procedure; peripheral angiography revealed stenosis of the abdominal aorta and distal peripheral arteries, which did not require intervention.

[Thoracic aortic transection following blunt trauma: two case reports]. / Künt travma sonrasi olusan torakal aortik transeksiyon: iki olgu sunumu.

Acute aortic transection after blunt trauma is a clinical situation, with a high mortality. When the other system injuries are predominant, the diagnosis could be possible only if it would be considered. These type of cases are usually die. The survivors are generally the cases of whom be diagnosed incidentally. Two cases who were admitted to our clinic due to falling down (suicide attempt) were diagnosed as aortic transection and were immediately operated. End to end graft interpositions were performed by using left atrio-femoral bypass in one patient and femoro-femoral bypass in the other. Systemic examinations of all the patients who are referred to the hospital after blunt trauma should be done completely and the physician should be alert for possible aortic transection or dissection.

Ascending aortic dissection without intimal tear: a case report.

Aortic dissection may occur without the presence of intimal tear, and it may occur with medial dissection and intramural hematoma. We report a case in which mediastinal enlargement was found in the chest x-ray of a 79-year-old patient with chest and back pain that had started suddenly 1 week before. The patient had a decrease in hematocrit, and transthoracic echocardiography revealed around the heart pericardial fluid 5 cm thick. The ascending aorta could not be evaluated because of the presence of this fluid. The preoperative diagnosis, based on the computerized tomography findings (dissection of ascending aorta and pericardial fluid), was ruptured dissection of the ascending aorta. The patient underwent an emergency operation. Two liters of hemorrhagic fluid was aspirated from the pericardium during the operation. The ascending aorta was opened, but there was no intimal tear. Medial dissection and intramural hemorrhage were seen. The ascending aorta was replaced with a tube graft. Cases such as this, of medial dissection and intramural hematoma in which intimal integrity is preserved, should be approached in the same manner as classical dissections with intimal tear.