An overlooked fact: thrombocytopenia following bioprosthetic aortic valve replacement.

INTRODUCTION: Thrombocytopenia observed after bioprosthetic aortic valve replacement has remained a puzzle to solve. AIM: To analyze thrombocytopenia occurring after bioprosthetic aortic valve replacement by comparison to mechanical aortic valve replacement and coronary artery bypass grafting procedures. MATERIAL AND METHODS: The study was conducted retrospectively on a total of 297 patients who underwent bioprosthetic aortic valve replacement, mechanical prosthetic aortic valve replacement and coronary artery bypass grafting at the cardiovascular surgery department of our clinical center between January 2013 and September 2017. Preoperative and postoperative first 14-day thrombocyte levels of the patients were analyzed. RESULTS: The postoperative blood thrombocyte level decrease was found to be more significant in patients who underwent bioprosthetic aortic valve replacement than in patients who underwent mechanical aortic valve replacement and coronary artery bypass grafting (p < 0.01). There was also a statistically significant difference in the time to reach the lowest postoperative platelet levels according to type of surgery (p = 0.001; p < 0.01). CONCLUSIONS: When compared to the patients who underwent coronary artery bypass grafting and mechanical prosthetic aortic valve replacement, postoperative thrombocytopenia was found to be more severe in patients who underwent bioprosthetic aortic valve replacement, with a dramatic decrease in thrombocyte count being observed on the postoperative second day. It was found that the thrombocytopenia recovers without causing any problem. We think that the shear forces may play a role in this recovery through washout of chemicals responsible for thrombocytopenia from the glutaraldehyde treated bioprostheses.

The effects of the metabolic syndrome on coronary artery bypass grafting surgery.

BACKGROUND: The metabolic syndrome (MS) is a clustering of factors that are associated with increased cardiovascular risk. A low-grade inflammatory process acts as the underlying pathophysiology, which suggests that the MS may have a detrimental effect on coronary interventions, including coronary artery bypass grafting (CABG) surgery performed with cardiopulmonary bypass (CPB). We aimed to evaluate the effect of the MS on morbidity and mortality rates in the early postoperative period in patients undergoing CABG. METHODS: We prospectively included 152 patients (109 males and 43 females; mean age 60.1 ± 8.6 years) who underwent elective CABG on CPB between January and September 2011. Early postoperative morbidity and mortality rates were compared between subjects with and without the MS. Diagnosis of the MS was based on the American National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) criteria. RESULTS: Of the study group, 64 patients (42%) had the MS. The two groups were similar in age and gender. In the postoperative period, rates of atrial fibrillation, wound infection, pulmonary complications, and lengths of intubation, hospitalisation and intensive care unit stay were significantly higher in MS patients (p < 0.01). The MS was significantly associated with wound infection (OR 6.64, 95% CI: 1.72-25.75), pulmonary complications (OR 6.44, 95% CI: 1.58-26.33), arrhythmia (OR 5.47, 95% CI: 1.50-19.97) and prolonged intubation (OR 1.17, 95% CI: 1.05-1.32). The mortality rate was 3.1% in the MS group and 1.1% in the non-MS group, with no significant difference (p > 0.05). CONCLUSION: The MS was associated with a higher rate of early postoperative morbidity following CABG, without having a significant effect on the mortality rate.

The effect of proximal anastomosis on the expansion rate of a dilated ascending aorta in coronary artery bypass surgery: a prospective study.

BACKGROUND: This study was designed to determine the short- and long-term effects of proximal aortic anastomosis, performed during isolated coronary artery bypass grafting (CABG) in patients with dilatation of the ascending aorta who did not require surgical intervention. METHODS: The study was performed on 192 (38 female and 160 male patients; mean age, 62.1 ± 9.2 years; range, 42-80 years) patients with dilatation of the ascending aorta who underwent CABG surgery between 1 June 2006 and 31 May 2014. In group 1 (n = 114), the saphenous vein and left internal mammarian artery grafts were used, and proximal anastomosis was performed on the ascending aorta. In group 2 (n = 78), left and right internal mammarian artery grafts were used, and proximal aortic anastomosis was not performed. Pre-operatively and in the first and third years postoperatively, the ascending aortic diameter was measured and recorded using transthoracic echocardiography at four different regions (annulus, sinus of Valsalva, sinotubular junction and tubular aorta). RESULTS: A statistically significant difference was found between the groups for the number of grafts used and the duration of aortic cross-clamping and cardiopulmonary bypass. No significant intergroup difference was seen for the mean diameter of the ascending aorta (p > 0.05). Annual changes in the aortic diameter were found to be extremely significantly different in both groups (p = 0.0001). Mean values of the aortic diameter at the level of the sinotubular junction and tubular ascending aorta, mean aortic diameters (p = 0.002 and p = 0.0001, respectively), annual increase in diameter (p = 0.0001 and p = 0.0001, respectively), and mean annual difference in diameter (p = 0.0001 and p = 0.0001, respectively) at one and three years postoperatively were statistically significantly different between the groups. CONCLUSION: In patients with ascending aortic dilatation who did not require surgical intervention and who had proximal anastomosis of the ascending aorta and underwent only CABG, we detected statistically significant increases in the diameter of the sinotubular junction and tubular aorta up to three years postoperatively.

Neurologic outcome in patients with cardiac arrest complicating ST elevation myocardial infarction treated by mild therapeutic hypothermia: The experience of a tertiary institution.

OBJECTIVE: Therapeutic hypothermia improves neurologic prognosis after cardiac arrest. The aim of this study was to report clinical experience with intravascular method of cooling in patients with cardiac arrest resulting from ST-segment elevation myocardial infarction (STEMI). METHODS: Thirteen patients (11 male, 2 famele; mean age was 39.6±9.4 years) who had undergone mild therapeutic hypothermia (MTH) by intravascular cooling after cardiac arrest due to STEMI were included. Clinical, demographic, and procedural data were analyzed. Neurologic outcome was assessed by Cerebral Performance Category (CPC) score. RESULTS: Anterior STEMI was observed in 9 patients. One patient died of cardiogenic shock complicating STEMI. Mean cardiopulmonary resuscitation (CPR) duration and door-to-invasive cooling were 32.9±20.1 and 286.1±182.3 minutes, respectively. Precooling Glasgow Coma Scale score was 3 in 9 subjects. Twelve patients were discharged, 11 with CPC scores of 1 at 1-year follow-up. No major complication related to procedure was observed. CONCLUSION: In comatose survivors of STEMI, therapeutic hypothermia by intravascular method is a feasible and safe treatment modality.

Long term outcomes of surgical revascularization for isolated left main coronary artery stenosis: a single-center surveillance study.

OBJECTIVE: The objective of this study was to retrospectively analyze the clinical course and postoperative long-term survival of patients diagnosed with isolated left main coronary artery (LMCA) stenosis after surgical revascularization. METHODS: A total of 38 patients (27 males, 11 females) who were diagnosed with isolated LMCA stenosis and underwent surgical revascularization were enrolled in the study. Isolated LMCA stenosis was classified into 2 groups: ostial stenosis and nonostial stenosis. Coronary events were defined as death of cardiac origin, the need for a new myocardial revascularization procedure, or the occurrence of myocardial infarction in the course of follow-up. The postoperative assessment period included short- and long-term follow-up. The study endpoint was defined as all-cause mortality. RESULTS: Among the 38 patients who participated in the study, 25 suffered from ostial LMCA stenosis. The early postoperative mortality rate before hospital discharge was 2.6%. Median duration of postoperative long-term follow-up was 73.43 months (range: 0.17-187.23). Median duration of long-term follow-up free from coronary events or percutaneous coronary interventions was 73.43 months. Postoperative 2-year survival rate was 97.4%, and 5-year survival rate was 92.1%. The postoperative survival period and period free of coronary events of patients with isolated ostial LMCA stenosis did not differ significantly from those of patients with nonostial stenosis (p=0.801, p=0.970, respectively). CONCLUSION: Postoperative short- and long-term prognosis of isolated LMCA stenosis appears good in terms of mortality and coronary event symptoms.

Unusual complication of aortic dissections: intimo-intimal intussusception.

Angiography with a pre-diagnosis of acute coronary syndrome was performed in a 76-year-old female patient presenting to another hospital with symptoms of chest pain and syncope. Upon determination of type III aortic dissection, the patient was referred to our clinic. On CT angiography, the ascending aortic diameter was 57 mm and no dissection flap was observed. There was a filling defect suggestive of intimo-intimal intussusception at the level of the aortic arch, occlusion of the left arteria carotid communis, and a double-channel aorta extending from the left subclavian artery to the iliac artery. On transoesophageal echocardiography, the ascending aorta was seen to be larger than normal and no dissection flap was observed. There were findings suggestive of haematoma and intimo-intimal intussusception at the proximal part of the aortic arch. The dissection flap causing occlusion in the vascular structures was resected. Supracoronary graft replacement of the ascending aorta was performed. Transoesophageal echocardiography is an invasive investigative method with high sensitivity and specificity for the diagnosis of intimo-intimal intussusception.

Infective endocarditis in Turkey: aetiology, clinical features, and analysis of risk factors for mortality in 325 cases.

OBJECTIVE: In order to define the current characteristics of infective endocarditis (IE) in Turkey, we evaluated IE cases over a 14-year period in a tertiary referral hospital. METHODS: All adult patients who were hospitalized in our hospital with a diagnosis of IE between 2000 and 2013 were included in the study. Modified Duke criteria were used for diagnosis. The Chi-square test, Student's t-test, Mann-Whitney U-test, Cox and logistic regression analysis were used for the statistical analysis. RESULTS: There were 325 IE cases during the study period. The mean age of the patients was 47 years. Causative microorganisms were identified in 253 patients (77.8%) and included staphylococci (36%), streptococci (19%), enterococci (7%), and Brucella spp (5%). A streptococcal aetiology was associated with younger age (<40 years) (p=0.001), underlying chronic rheumatic heart disease (CRHD) (odds ratio (OR) 3.89) or a congenital heart defect (OR 4.04), community acquisition (OR 17.93), and native valve (OR 3.68). A staphylococcal aetiology was associated with healthcare acquisition (OR 2.26) or pacemaker lead-associated endocarditis (OR 6.63) and an admission creatinine level of >1.2mg/dl (OR 2.15). Older age (>50 year) (OR 3.93), patients with perivalvular abscess (OR 9.18), being on dialysis (OR 6.22), and late prosthetic valve endocarditis (OR 3.15) were independent risk factors for enterococcal IE. Independent risk factors for mortality in IE cases were the following: being on dialysis (hazard ratio (HR) 4.13), presence of coronary artery heart disease (HR 2.09), central nervous system emboli (HR 2.33), and congestive heart failure (HR 2.15). Higher haemoglobin (HR 0.87) and platelet (HR 0.996) levels and surgical interventions for IE (HR 0. 33) were found to be protective factors against mortality. CONCLUSIONS: In Turkey, IE occurs in relatively young patients and Brucella spp should always be taken into consideration as a cause of this infection. We should first consider streptococci as the causative agents of IE in young patients, those with CRHD or congenital heart valve disease, and cases of community-acquired IE. Staphylococci should be considered first in the case of pacemaker lead IE, when there are high levels of creatinine, and in cases of healthcare-associated IE. Enterococci could be the most probable causative agent of IE particularly in patients aged >50 years, those on dialysis, those with late prosthetic valve IE, and those with a perivalvular abscess. The early diagnosis and treatment of IE before complications develop is crucial because the mortality rate is high among cases with serious complications. The prevention of bacteraemia with the measures available among chronic haemodialysis patients should be a priority because of the higher mortality rate of subsequent IE among this group of patients.

Methicillin-resistant Staphylococcus aureus infection: an independent risk factor for mortality in patients with poststernotomy mediastinitis.

OBJECTIVE: The mortality rate of patients with poststernotomy mediastinitis remains very high. The aim of this study was to identify the risk factors associated with mortality in these patients. SUBJECTS AND METHODS: Surveillance of sternal surgical-site infections including mediastinitis was carried out for adult patients undergoing a sternotomy between 2004 and 2012. Criteria from the US Centers for Disease Control and Prevention were used to make the diagnosis. All data on patients with a diagnosis of mediastinitis who were included in the study and on mortality risk factors were obtained from the hospital database and then analyzed using SPPS 16.0 for Windows. RESULTS: Of the 19,767 patients undergoing open heart surgery, 117 (0.39%) had poststernotomy mediastinitis; 32% of these 117 died. The independent risk factors for mortality were methicillin-resistant Staphylococcus aureus (MRSA) [odds ratio (OR) 12.11 and 95% confidence interval (CI) 3.15-46.47], intensive-care unit stays >48 h after the first operation (OR 11.21 and 95% CI 3.24-38.84) and surgery that included valve replacement (OR 6.2 and 95% CI 1.44-27.13). The mortality rate decreased significantly, dropping from 38% (34/89) between 2004 and 2008 to 14% (4/28) between 2009 and 2012 (p = 0.018). CONCLUSION: In this study, elimination of MRSA from the hospital setting decreased the rate of mortality in patients with poststernotomy mediastinitis.

The role of Porphyromonas gingivalis in the development of atherosclerosis and its relationship with fim A genotype.

BACKGROUND: Porphyromonas gingivalis, a major periodontal pathogen, is gaining increasing attention for its possible association with atherosclerosis. Its fimbriae are classified into six genotypes (Types I-V, Ib) based on the diversity of the fim A genes encoding the fimbrial subunits. In this study, fim A genotype's distribution of P. gingivalis was analyzed in atherosclerotic plaque specimens. METHODS: A total of 50 atherosclerotic plaque specimens and 50 non-atherosclerotic, post stenotic aneurysm specimens were collected from patients undergoing cardiovascular surgery. Bacterial DNA was also extracted from each specimen, as real-time PCR was carried out with P. gingivalis-specific primer sets. The positive specimens of P. gingivalis were further analyzed to discriminate the fim A genotype using real-time and nested PCR methods. RESULTS: P. gingivalis was detected only in one atherosclerotic plaque; however, the genotype was nontypable in this specimen. CONCLUSIONS: We state that it is not easy to show a significant relationship between P. gingivalis, its fim A genotype, and atherosclerosis. We suggest that new extended studies based especially upon the quantitave determination of P. gingivalis and its genotype distribution on atherosclerotic specimens are needed to show an evident relationship between atherosclerosis and P. gingivalis.

Results for surgical closure of isolated ventricular septal defects in patients under one year of age.

BACKGROUND: This study evaluated the outcomes of patients undergoing surgical repair of isolated ventricular septal defect (VSD) in the first year of life with particular attention to age and severity of pulmonary hypertension (PH). METHODS: Between July 1, 2002 and May 31, 2012, 282 patients aged less than one year underwent isolated VSD closure at a median age of five months (range, 21 days to 1 year) and a median weight of 5.3 kg (range, 2.9 to 12.5 kg). Patients were divided into three groups according to the age at surgery (0-3, 3-6, and 6-12 months), and groups were compared in regard to severity of PH associated with morbidity and mortality. RESULTS: Four (1.4%) early and four (1.4%) late deaths occurred postoperatively. All mortalities were patients with severe PH, aged between 3 and 12 months. Although hemodynamic studies revealed a higher incidence of persistent postoperative PH in patients above three months of age, there was no statistically significant difference in morbidity associated with prolonged mechanical ventilation, and long intensive care unit and hospital stays between age-related groups. CONCLUSION: In this study, the incidence of mortality was higher in patients over three months of age undergoing repair of isolated VSD; the data suggest that the mortality may be decreased in patients with severe PH who were operated on earlier in life. We conclude that in infants with severe PH, early surgical repair (less than three months) of isolated VSDs is strongly advised to achieve more favorable results.

Results for surgical correction of complete atrioventricular septal defect: associations with age, surgical era, and technique.

BACKGROUND: This study was conducted to evaluate the outcomes of patients undergoing complete atrioventricular septal defect (CAVSD) repair with particular attention to age at surgery, surgical era, and technique. METHODS: One hundred and forty-seven patients undergoing CAVSD repair between November 2002 and February 2012 were grouped according to surgical era and technique. Group I (age: 9.4 ± 5.0 months; weight: 6.8 ± 1.7 kg) consisted of 45 patients, operated before August 2006, and was divided into subgroup Ia (31 patients; two-patch repair) and subgroup Ib (14 patients; modified single-patch repair). One hundred and two patients operated after August 2006 were included in Group II (age: 5.2 ± 3.1 months; weight: 4.9 ± 2.6 kg), and was divided into subgroup IIa (59 patients; two-patch repair) and subgroup IIb (43 patients; modified single-patch repair). Groups were compared with regard to perioperative variables and postoperative data. RESULTS: There were 19 early and five late deaths. Overall mortality was significantly higher in Group I, compared to Group II (p < 0.01). Comparison of Groups Ia to Ib and IIa to IIb revealed no statistically significant difference in mortality or morbidity. Age >8 months and preoperative common atrioventricular valve (CAVV) regurgitation ≥ moderate were significant risk factors for mortality and morbidity. After 40.8 ± 24.4 months, 99 (80.4%) of 123 (83.7%) survivors were asymptomatic without any medication, and 24 (19.5%) have mild symptoms. CONCLUSION: Our current results indicate that younger patient age and better preoperative CAVV functions were the main factors for a favorable outcome after surgical correction of CAVSD; and outcomes did not differ by the surgical technique.

Early and intermediate term results for surgical correction of total anomalous pulmonary venous connection.

BACKGROUND: This retrospective study evaluated factors associated with mortality and morbidity in patients having functionally biventricular heart (FBH) and functionally univentricular heart (FUH) undergoing total anomalous pulmonary venous connection (TAPVC) repair. METHODS: We reviewed medical records retrospectively and identified 72 patients undergoing TAPVC repair between July 2002 and December 2010; and 62 patients had FBH and 10 patients had FUH. The median age and weight at repair was 9.1 months (range, 8 days-16 years) and 6.7 kg (range, 2.5-57 kg). The TAPVC anatomy was supracardiac in 41 (56.9%), cardiac in 18 (25%), infracardiac in eight (11.1%), and mixed in five patients (6.9%). RESULTS: There were seven early deaths (2 FBH [25%] and 5 FUH [62.5%]) and one late death (FUH). Presence of FUH (p < 0.01), heterotaxy syndrome (p = 0.03), young age (p < 0.01), low weight (p < 0.01) and long CPB time (p = 0.04) at the time of surgery were statistically significant risk factors for mortality. Morbidity was related to long duration of postoperative mechanical ventilation, intensive care unit and hospital stay. Presence of FUH was the only significant risk factor for morbidity (p < 0.01). After a mean follow-up of 52.1 months (range, 3-74 months), 59 (92%) of 64 survivors were asymptomatic without any medication, and five have mild symptoms with regular physical activity. CONCLUSION: Operative results of TAPVC have dramatically improved in recent years. However, patients having FUH (especially with concomitant palliative surgery), heterotaxy syndrome, low weight, early age, and long CPB time still have an increased operative mortality.

Preoperative risk factors for in-hospital mortality and validity of the Glasgow aneurysm score and Hardman index in patients with ruptured abdominal aortic aneurysm.

The aim of this study is to evaluate the validity of the Glasgow aneurysm score (GAS) and Hardman index in patients operated on because of ruptured abdominal aortic aneurysm (rAAA), and determining preoperative risk factors that affect in-hospital mortality. One hundred one patients operated on to repair a rAAA within the last 10 years were included. The GAS and Hardman index were calculated for each patient separately. The relation between in-hospital mortality and the Hardman index and GAS was analyzed by means of the receiver-operator characteristic (ROC) curve. Univariate and multivariate methods of analyses were used to determine preoperative risk factors. Average age was 69 ± 8, and in-hospital mortality rate was 51.5%. Analysis of the ROC curve showed that the Hardman index had an area under the curve (AUC) = 0.71 (95% confidence interval [CI], 0.593-0.800, P = 0.0002) for predicting in-hospital mortality. The GAS had an AUC = 0.77 (95% CI, 0.680-0.851, P < 0.0001). The results of multivariate analysis revealed the presence of the following preoperative risk factors: age more than 63 years (odds ratio [OR], 4.4; 95% CI, 1.17-16.49, P = 0.028); loss of consciousness (OR, 9.33; 95% CI, 1.94-44.86, P = 0.005); creatinine higher than 1.7 mg/dL (OR, 5.52; 95% CI, 1.92-15.85, P = 0.001); and pH lower than 7.31 (OR, 3.77; 95% CI, 1.18-11.99, P = 0.024). In conclusion, the Hardman index and GAS have a significant correlation with in-hospital mortality rates. Nevertheless, a high score does not necessarily correspond with a definite mortality. This is why scoring systems could not be considered as the sole criterion for choosing patients for this study. Clinical experience was still the leading factor in deciding against or in favor of surgery.

Randomized comparison between mild and moderate hypothermic cardiopulmonary bypass for neonatal arterial switch operation.

OBJECTIVES: To compare neonates receiving arterial switch operation (ASO) either with mild or moderate hypothermic cardiopulmonary bypass. METHODS: Forty neonates undergoing ASO were randomized to receive either mild (Mi > 32 °C, n = 20) or moderate (Mo > 26 °C, n = 20) hypothermic cardiopulmonary bypass (CPB) between April 2007 and June 2010. All patients were diagnosed with simple transposition of the great arteries. Mean age (Mi: 8.32 ± 4.5 days, Mo: 7.54 ± 5.0 days, P = 0.21) and body weight were similar in both groups (Mi: 3.64 ± 0.91 kg, Mo: 3.73 ± 0.84 kg, P = 0.14). Follow-up was 3.1 ± 2.5 years for all patients. RESULTS: Lowest perioperative rectal temperature was 33.5 ± 1.4 °C (Mi) versus 28.2 ± 2.1 °C (Mo) (P < 0.001). All patients safely weaned from CPB required lower doses of dopamine (Mi: 5.1 ± 2.4 µg/kg min, Mo: 6.5 ± 2.1 µ/kg min, P = 0.04), dobutamine (Mi: 7.2 ± 2.5 µg/kg min, Mo: 8.6 ± 2.4 µ/kg min, P = 0.04) and adrenalin (Mi: 0.02 ± 0.02 µg/kg min, Mo: 0.05 ± 0.03 µ/kg min, P = 0.03) in mild hypothermia group. Intraoperative blood transfusion (Mi: 190 ± 58 ml, Mo: 230 ± 24 ml, P = 0.03) and postoperative lactate levels (Mi: 2.7 ± 0.9 mmol/l, Mo: 3.1 ± 2.2 mmol/l, P = 0.02) were lower under mild hypothermia. Secondary chest closure was performed in 30% (Mi) versus 35% (Mo) (P = 0.65). Duration of inotropic support (Mi: 7 (4-11) days, Mo: 11 (7-15) days, P = 0.03), time to extubation (Mi: 108 (88-128) h, Mo: 128 (102-210) h, P = 0.04), lengths of intensive care unit (ICU) stay (Mi: 9 (5-14) days, Mo: 12 (10-18) days, P = 0.04) and hospital stay (Mi: 19 (10-29) days, Mo: 23 (15-37) days, P = 0.04) were significantly shorter under mild hypothermia. Two-year freedom from reoperation was 100% for both the groups. CONCLUSIONS: The ASO under mild hypothermia seemed to be beneficial for pulmonary recovery, need for inotropic support and length of ICU and hospital stay. No worse early- or intermediate-term effects of mild hypothermia were found.

Surgical treatment of infective valve endocarditis in children with congenital heart disease.

OBJECTIVE: This study assesses surgical procedures, operative outcome, and early and intermediate-term results of infective valve endocarditis in children with congenital heart disease. METHODS: Seven consecutive children (five females, two males; mean age, 10.8 years) who underwent surgery for infective valve endocarditis between 2006 and 2010 were included in the study. The aortic and mitral valves were affected in two and tricuspid in five patients. Indications for operation included cardiac failure due to atrioventricular septal rupture, severe tricuspid valve insufficiency, and septic embolization in one, moderate valvular dysfunction with vegetations in three (two tricuspid, one mitral), and severe valvular dysfunction with vegetations in the other three patients (two tricuspid, one mitral). The pathological microorganism was identified in five patients. Tricuspid valve repair was performed with ventricular septal defect (VSD) closure in five patients. Two patients required mitral valve repair including one with additional aortic valve replacement. RESULTS: There were no operative deaths. Actuarial freedom from recurrent infection at one and three years was 100%. Early echocardiographic follow-up showed four patients to have mild atrioventricular valve regurgitation (three tricuspid and one mitral) and three had no valvular regurgitation. No leakage from the VSD closure or any valvular stenosis was detected postoperatively. CONCLUSIONS: Mitral and tricuspid valve repairs can be performed with low morbidity/mortality rates and satisfactory intermediate-term results in children with infective valve endocarditis.

Computed tomography evaluation of different chest tube sites for residual pleural volumes after coronary artery bypass surgery.

BACKGROUND AND OBJECTIVES: We investigated the efficacy of pleural drainage with the use of different chest tube methods in patients after coronary artery bypass graft (CABG) surgery. DESIGN AND SETTING: Prospective randomized study of 60 patients undergoing elective on-pump single CABG surgery. PATIENTS AND METHODS: The left internal mammary arterial grafts were harvested from all patients. The patients were separated into three groups: In one group (IC6, n=20), pleural tubes were inserted through the sixth intercostal space at the midaxillary line; in the second group (SX-r, n=20), rigid straight pleural tubes were inserted from the mediastinum through the subxiphoid area; and in the third group (SX-s, n=20), soft curved drainage tubes were inserted from the mediastinum through the subxiphoid area. The residual pleural effusion was examined by multislice CT scans within 8 hours of removal of the drainage tubes. Pain was evaluated according to standard methods. RESULTS: The groups did not differ with respect to volume of residual pleural effusion (P >.05). The IC6 group had a higher mean pain score than the other two groups (P <.05), whose mean pain scores did not differ significantly from each other (P >.05). IC6 group patients had a higher requirement for analgesics. The rate of atelectasis was higher in group IC6 (P <.05). CONCLUSION: CT scans revealed that different chest tube insertion sites have the same efficiency for draining of pleural effusion, although drainage tubes inserted through the thoracic cage may result in more severe pain.

Asymmetric dimethylarginine levels in Buerger's disease.

BACKGROUND: Endothelial dysfunction may play a major role in both peripheral arterial disease (PAD) and Buerger's disease (BD). Asymmetric dimethylarginine (ADMA) is an endogenous inhibitor of endothelial nitric oxide synthase and increased ADMA levels impair vascular homeostasis. We aimed to determine the plasma levels of ADMA and evaluate the relationship of ADMA levels with smoking and clinical severity of the disease in patients with BD and to compare these results with those of patients with PAD and healthy individuals. METHODS: In our center, 45 patients undergoing peripheral arterial surgery, 28 patients being followed up for BD, and 24 healthy individuals without vascular or cardiac disease, were enrolled in the study. Intra- and intergroup analysis was performed to evaluate the relationship of ADMA levels with smoking behaviors and clinical disease severity according to Fontaine classification. RESULTS: ADMA levels were 1.26 ± 0.76 mmol/L, 0.87 ± 0.27 mmol/L, and 1.07 ± 0.88 mmol/L in patients with PAD, in patients with BD, and in the control group, respectively. ADMA levels were significantly higher in patients with PAD than those in control patients (p = 0.003) and the levels observed in patients with BD were significantly lower than those in control patients (p = 0.001). Smokers with PAD had higher ADMA levels than smokers with BD (p = 0.03). ADMA levels were higher in patients with Fontaine stage III and IV disease than those with Fontaine stage II diseases, for patients with PAD as well as those with BD. CONCLUSION: The lower ADMA levels observed in patients with BD might be related to the degradation of ADMA by dimethylarginine dimethylaminohydrolase in response to ischemia and could act as a defensive mechanism during the acute or quiescent phases. In patients with BD experiencing severe clinical conditions or with a longer time course for the disease, higher ADMA levels may suggest a poor prognosis.

A novel provisional aortopulmonary shunt may help avoid neonatal cardiopulmonary bypass: report of two cases.

A novel temporary aortopulmonary shunt, constructed between the aorta and main pulmonary artery with flexible cannulas, was used to facilitate right ventricular outflow tract reconstruction in one neonate and creation of a central aortopulmonary shunt in a second neonate. Although cardiopulmonary bypass is readily available in Turkey, the strategy described in the case report may prove especially useful in developing nations with limited access to cardiopulmonary bypass (CPB).