[Show abstract][Hide abstract] ABSTRACT: Emerging perioperative genomics may influence the direction of risk assessment and surgical strategies in cardiac surgery. The aim of this study was to investigate whether single nucleotide polymorphisms (SNP) affect the clinical presentation and predispose to increased risk for postoperative adverse events in patients undergoing coronary artery bypass grafting surgery (CABG).
A total of 220 patients undergoing first-time CABG between January 2005 and May 2008 were screened for factor V gene G1691A (FVL), prothrombin/factor II G20210A (PT G20210A), angiotensin I-converting enzyme insertion/deletion (ACE-ins/del) polymorphisms by PCR and Real Time PCR. End points were defined as death, myocardial infarction, stroke, postoperative bleeding, respiratory and renal insufficiency and event-free survival. Patients were compared to assess for any independent association between genotypes for thrombosis and postoperative phenotypes.
Among 220 patients, the prevalence of the heterozygous FVL mutation was 10.9% (n = 24), and 3.6% (n = 8) were heterozygous carriers of the PT G20210A mutation. Genotype distribution of ACE-ins/del was 16.6%, 51.9%, and 31.5% in genotypes I/I, I/D, and D/D, respectively. FVL and PT G20210A mutations were associated with higher prevalence of totally occluded coronary arteries (p < 0.001). Furthermore the risk of left ventricular aneurysm formation was significantly higher in FVL heterozygote group compared to FVL G1691G (p = 0.002). ACE D/D genotype was associated with hypertension (p = 0.004), peripheral vascular disease (p = 0.006), and previous myocardial infarction (p = 0.007).
FVL and PT G20210A genotypes had a higher prevalence of totally occluded vessels potentially as a result of atherothrombotic events. However, none of the genotypes investigated were independently associated with mortality.
Full-text · Article · Sep 2011 · Journal of Cardiothoracic Surgery
[Show abstract][Hide abstract] ABSTRACT: An arterial pseudoaneurysm is a cavity which does not consist of three layers of arterial wall and is generally seen at femoral and radial artery sites due to bone fractures, arterial injuries and iatrogenic reasons such as catheterization. The treatment choice may be either surgical or conservative. Patients with pseudoaneurysm should be carefully followed and the treatment choice should be immediately decided to avoid possible complications. We report a case of pseudoaneurysm formation in the radial artery that occurred one week after arterial catheterization for coronary angiography. The treatment choice for this patient was surgical and he was discharged without any complications.
[Show abstract][Hide abstract] ABSTRACT: This prospective, randomized study assessed the prophylactic effects of indomethacin treatment on pericardial effusion after aortic surgery.
Eighty-five patients were found eligible to participate in this double-blind study. Patients were assigned to a control group receiving oral placebo or to an indomethacin group receiving 25 mg oral indomethacin 3 times daily for 7 days preoperatively. After aortic surgery, patients were followed up clinically and evaluated for pericardial effusion with transthoracic echocardiography on the first and seventh postoperative days during hospitalization and at the second and sixth weeks after discharge.
The demographic and the operative data were similar between groups. The surgical interventions included Bentall procedure in 63 patients, valve-sparing procedures in 7 patients, and supracoronary ascending aorta replacement in 15 patients. Hemiarch replacement was performed in 16 patients. No patient in either group had pericardial effusion after the first postoperative day. At the end of the first week, however, 2 patients had pericardial effusion, at the end of the second week after discharge, 3 patients had pericardial effusion, and at the end of the sixth week after discharge, 4 patients had PEs. One of the patients who had PE at the end of the sixth week received indomethacin; the others were all in the control group, a significant difference (P=.019). Five patients underwent transthoracic echocardiographically guided pericardiocentesis; 4 underwent surgical pericardiocentesis.
Indomethacin may have beneficial effects on the outcomes and incidence of postoperative pericardial effusion after aortic surgery.
No preview · Article · Feb 2011 · The Journal of thoracic and cardiovascular surgery
[Show abstract][Hide abstract] ABSTRACT: We aimed to identify characteristics differentiating patients undergoing mitral valve replacement versus valve repair for mitral regurgitation (MR) and to investigate retrospectively mid-term clinical and functional outcomes.
From January, 2004 to January, 2009 146 patients underwent mitral valve surgery (62 male / 84 female; age: 55.9+/-13.6 [18-80] years) by one surgical team. Mitral valve replacement was performed in 101 patients (69.2 %) and valve repair was performed in 45 patients (30.8%). Mean follow-up time was 586+/-413 days. Life tables were constructed for the analysis of 5-year complication free survival and comparisons were performed between the groups using Log-rank test within 95%CI.
The choice of surgical technique depended on the etiology of MR. Degenerative (p=0.001) and ischemic (p=0.014) MR were more common in patients undergoing repair whereas patients with complex rheumatic mitral valve disease (p=0.001) with subvalvular involvement commonly underwent replacement. Overall 30-day mortality was 3.2% (replacement, 3.96%vs repair, 2.22%, p=0.59). Although there was no significant difference between the groups regarding baseline left ventricular ejection fraction (EF) (ischemic p=0.61; non-ischemic p=0.34), improvement was more pronounced in the repair group for both etiologies (ischemic MR, p=0.001; non- ischemic MR p=0.002). Survival at 5-years was 91.7+/-4.7% after repair and 83.5+/-9.2% after replacement, respectively (p=0.83). Freedom from grade 2 or more mitral regurgitation, reoperation, endocarditis, and thromboembolism were 95+/-5% vs 97+/-3% (p=0.71); 95+/-4% vs 98+/-2% (p=0.98); 94+/-4% vs 100% (p=0.16); and 85+/-8% vs 100% (p=0.095) in replacement and repair groups, respectively.
This study demonstrates that mitral valve repair is associated with an acceptable operative mortality, satisfactory mid-term survival and better preservation of left ventricular function. Significant differences in favor of repair are expected in long-term follow-up particularly regarding freedom from thromboembolism and endocarditis.
No preview · Article · Aug 2010 · Anadolu kardiyoloji dergisi: AKD = the Anatolian journal of cardiology
[Show abstract][Hide abstract] ABSTRACT: Background: The aim of this study was to investigate the role of apoptosis in the pathogenesis of atrial fibrillation (AF). Methods: Thirty consecutive patients submitted for mitral valve surgery were investigated. Eleven patients with permanent AF (6 males, 5 females; mean age 57.7±13.1 years; range 36 to 76 years) were considered as the AF group whereas 19 patients who were in sinus rhythm (11 males, 8 females; mean age 64.1±8.4 years; range 48 to 77 years) were selected as control subjects. Mean left atrial diameter determined by echocardiography was 54.8±3.4 mm in the AF group compared to 40.7±4.1 mm in controls (p=0.001). The right atrial appendage tissue samples were excised before extracorporeal circulation in all patients. We assessed the onset of in situ DNA fragmentation by using the TUNEL assay. Furthermore, we examined the expression pattern of anti-apoptotic Bcl-2 and pro-apoptotic Bax proteins using immunohistochemistry. Results: Bax and Bcl-2 expression were similar between the AF group and control subjects (16.2% versus 15.1%, p=0.73; 14.6% versus 16.1%, p=0.64, respectively). However, when compared with controls, atrial myocyte apoptosis was significantly higher within the AF group (mean apoptotic index, 21.9% versus 11.8% respectively, p=0.002). Atrial tissue from permanent AF-affected individuals had atrial myocyte nuclei that were positive for TUNEL whereas control subjects had either TUNEL negative or low-grade TUNEL positivity. Conclusion: This pilot study demonstrated a positive correlation between AF and DNA fragmentation, a terminal determinant of apoptosis. The results suggest a potential link between the pathogenesis of permanent AF and atrial myocyte apoptosis. Targeted anti-apoptotic strategies may have a clinical value by preventing atrial remodeling and fibrosis.
[Show abstract][Hide abstract] ABSTRACT: The aim of the present study was to determine whether oral pretreatment with micronized purified flavonoid fraction (Daflon) has beneficial effects on cardiac function and outcome after cardiac operations. This prospective, randomized trial enrolled 43 patients who had an impaired preoperative left ventricular ejection fraction of less than 0.50 (mean, 0.45 +/- 0.04) and a mean New York Heart Association functional class status of 2.30 +/- 0.74; all were scheduled for elective coronary artery bypass grafting. Patients who were randomized to the Daflon group (n=21) received oral Daflon 500 mg (6 tablets daily for 4 days, followed by 2 tablets for 3 days) preoperatively. Outcome variables included perioperative hemodynamic data, inotropic requirements, morbidity, and death, as well as cardiac ischemia and various outcome markers. Hemodynamic and biochemical data were collected before induction of anesthesia, perioperatively before starting cardiopulmonary bypass, immediately after bypass, and at the 24th postoperative hour. There was only 1 death (in the Daflon group). During the post-cardiopulmonary bypass period, troponin I and lactate dehydrogenase levels were significantly lower in the Daflon group. Also, the New York Heart Association status of the patients in the Daflon group was significantly lower postoperatively. Differences between the 2 groups in lengths of stay in the intensive care unit and hospital, inotropic requirements, and left ventricular ejection fraction levels did not reach statistical significance. Orally administered Daflon might provide better outcomes for patients who have impaired cardiac function before undergoing cardiac operations that require cardiopulmonary bypass.
Full-text · Article · Apr 2010 · Texas Heart Institute journal / from the Texas Heart Institute of St. Luke's Episcopal Hospital, Texas Children's Hospital
[Show abstract][Hide abstract] ABSTRACT: The level of thyroid hormones is an important factor in determining the outcome of coronary artery bypass patients. Sodium nitroprusside (SNP) is a natural donor of nitric oxide which has been shown to interfere with thyroid hormone synthesis. Whether clinical use of sodium nitroprusside has any effect on thyroid function has not yet been investigated. The aim of this study was to investigate the effects of SNP administration on circulating levels of thyroid hormones.
One hundred and six consecutive patients who underwent coronary artery bypass grafting operation were prospectively randomized to receive continuous infusions of either SNP or saline limited to the rewarming time of cardiopulmonary bypass (CPB). Free triiodothyronine (T3), total T3, free thyroxine (T4), total T4 and thyroid-stimulating hormone (TSH) levels were analyzed.
Free T3, TSH and albumin changes of SNP and control groups were statistically different from each other. In the SNP group, free T3 values stayed in the euthyroid range between CPB and post-CPB periods, the period when SNP was infused, whereas it continued to decline to hypothyroidic levels in the control group. In addition, in the SNP group, an elevation in TSH levels was observed during the CPB period. Postoperatively, an earlier restoration of free T3 and TSH levels was observed in the SNP group when compared to the control group.
In this study, administration of SNP during cardiopulmonary bypass is shown to regulate free T3 and TSH levels positively.
No preview · Article · Mar 2010 · Journal of Cardiovascular Medicine
[Show abstract][Hide abstract] ABSTRACT: Brucellosis is frequently seen in Mediterranean and Middle East countries, including Turkey. We report the medical and surgical management of 31 cases of native endocarditis.
Thirty-one patients were admitted to our clinic with suspected Brucella Endocarditis. The diagnosis was established by either isolation of Brucella species, or the presence of antibodies. Following preoperative antibiotic therapy patients underwent valve replacement with excessive tissue debridement. Patients were followed up with Brucella titers, blood cultures, and echocardiography.
On admission all patients were febrile and mostly dyspneic (NYHA Class 3 or 4). The blood tests were normal except for elevated ESR, CRP and serological tests. The aortic valve was involved in 19 patients, mitral valve in 7 patients, and both valves in 5. After serological confirmation of BE, antibiotic therapy was maintained. Twenty-five of the patients received rifampicine, doxycycline, and cotrimaxozole; 2 of them received a combination of rifampicine, streptomycin, and doxycycline; and 4 of them received rifampicine, tetracycline, and cotrimaxozole. Tissue loss in most of the affected leaflets and vegetations were presenting all patients. Valve replacements were performed with mechanical and biologic prostheses. All the patients were afebrile at discharge but received the antibiotics for 101, 2+/-16, 9 days. The follow-up was 37, 1+/-9, 2 months.
In our retrospective study, combination of adequate medical and surgical therapy resulted in declined morbidity and mortality rate. The valve replacement with aggressive debridement is the most important part of the treatment, which should be supported with efficient preoperative and long term postoperative medical treatment.
Full-text · Article · Feb 2010 · Clinical Cardiology
[Show abstract][Hide abstract] ABSTRACT: To assess the results of bilateral pectoralis major muscle flaps (BPMMF) and vacuum-assisted closure (VAC) at different stages of postcardiac surgery mediastinitis.
Of 65 patients with a deep sternal wound infection (DSWI) after cardiac surgery, 33 with a stable sternum were treated with VAC (59.3 +/- 11.7 years of age) and 32 with an unstable sternum or osteomyelitis (63.3 +/- 9.8 years of age) were treated with early BPMMF and continuous irrigation. Delayed BPMMF reconstruction was necessary in six VAC patients.
The overall incidence of DSWI was 1.04% within the study period. Deep sternal wound infection was diagnosed 15.9 +/- 10.8 days (range 5-62 days) after surgery. Diabetes was more common in the BPMMF group than in the VAC group (P = 0.046). Hospital mortality after treatment was 4.6% (n = 3) overall. Causes of death were septic multiorgan failure and respiratory failure. The infective pathogens were methicillin-resistant Staphylococcus aureus (MRSA; n = 2) and Acinetobacter species (n = 1). The median hospital stay was 29 days (range 15-110 days). After 6 months, only one recurrent sternal infection had occurred in the VAC group.
Early BPMMF is an effective surgical treatment for DSWI in patients with an unstable sternum and osteomyelitis. VAC may be considered for patients without osteomyelitis but a stable sternum, or as adjuvant therapy in patients with comorbidity.
[Show abstract][Hide abstract] ABSTRACT: Objective: Cell therapy for patients with ischaemic cardiomyopathy (IC) is still an open issue. We aimed to assess the long-term safety and therapeutic potency of autologous bone marrow mononuclear cell (ABMMNC) implantation into ungraftable coronary artery (UCA) territories in patients with IC. Methods: Bone marrow was aspirated from the iliac crest, and transepicardial ABMMNC implantation (n = 25, 24 men, aged 57 ± 7 years) as an adjunct to coronary artery bypass grafting (CABG) was performed into an area of reversible ischaemia within the territory of UCA (1.29 ± 0.09 × 109 ABMMNCs). Control group (n = 25, 23 men, aged 59 ± 7 years) underwent incomplete CABG due to poor target vessel graftability. The study protocol consisted of coronary angiography, stress echocardiography, nuclear imaging and Holter monitoring at baseline and follow-up. The mean follow-up time was 988 ± 423 days. Results: There was no difference between the groups regarding postoperative complications and outcome. Overall 5-year survival for the ABMMNC group was 79 ± 10%, and 71 ± 12% for the controls (p = 0.48). Left ventricular ejection fraction (LVEF) at baseline was 24.8 ± 3.7 versus 25.9 ± 3.1 in the ABMMNC group and the controls, respectively. After 6 months, mean global LVEF increased to 36.3 ± 7.4 (p < 0.001) versus 31.4 ± 4.1 (p = 0.001), respectively. A significant difference was noted in delta LVEF between the groups (p < 0.001, 95% confidence interval (CI): 3.4–8.9) at 6 months, and (p = 0.001, 95% CI: 2.0–7.4) at 1 year. Accordingly, perfusion scores in UCA segments detected by single-photon emission computed tomography (SPECT) improved with ABMMNC therapy to 18.0 ± 24.4 from 7.1 ± 25.7 (p = 0.001 vs control UCA segments). Conclusion: Cellular therapy for IC within UCA could augment myocardial perfusion and contractility but does not improve overall survival. No adverse events were detected after cell therapy at mid-term follow-up.
Full-text · Article · Oct 2009 · European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery
[Show abstract][Hide abstract] ABSTRACT: Mesenchymal stem cells (MSCs) have the capacity to differentiate into osteoblasts, chondrocytes, adipocytes, myocytes, and cardiomyocytes. Several established methods are presently available for in vitro isolation of MSCs from bone marrow. However, the duration necessary to culture them can be a major handicap to cell-based therapies needed for such urgent cardiovascular conditions as acute myocardial infarction and acute hindlimb ischemia. The best timing of cardiomyocyte differentiation induction after MCS isolation and expansion is still an unresolved issue. Our goal was to investigate the possibility of obtaining functional cardiomyocytes from rat MSC within a shorter time period. We examined MSCs' colony-forming capacity, CD90 and CD34 immunoreactivity during the 14 days of culturing. Cardiomyocyte differentiation was induced by 5-azacytidine. Immunohistochemic staining, together with intracellular Ca2+ measurement experiments, revealed that MSCs do not differentiate into any specific cell lineage but show the characteristics of MSCs on both the 9th and 14th days of the culture. To check the potential for differentiation into cardiomyocytes, experiments with caffeine application and depolarization with KCl were performed. The cells possessed some of the specific biochemical features of contracting cells, with slightly higher capacities on the 14th day. Cells from 9th and 14th days of the culture that were treated with 5-azacytidine had a higher expression of cardiac-specific markers such as troponin I, alpha-sarcomeric actin, and MEF2D compared with the control groups. This study illustrates that it is possible to get functional cardiomyocytes from in vitro MSC culture in a shorter time period than previously achieved. This reduction in time may provide emergency cases with access to cell-based therapies that may have previously been unavailable.
No preview · Article · Mar 2009 · Canadian Journal of Physiology and Pharmacology
[Show abstract][Hide abstract] ABSTRACT: We aimed to preserve sternal vascularity better by harvesting only midsegment of the right internal thoracic artery (RITA) than using conventional bilateral internal thoracic artery (BITA) harvesting method, and we evaluated the sternal vascularity with single photon emission computed tomography (SPECT).
In this prospective clinical randomized investigation, 135 patients undergoing coronary artery bypass surgery (CABG) were divided into three groups: Full-RITA group who had a full length of both ITA as a graft for CABG (n=45); mid-RITA group - a midsegment of RITA and left internal thoracic artery (LITA) (n=45); and non-RITA group who had only LITA (n=45). Before and after surgery, all patients underwent a bone scan with single photon emission computed tomography (SPECT) to evaluate the sternal vascular activity. Comparisons of variables were performed by Chi-square, ANOVA, Tukey HSD and paired t test as appropriate. The Bonferroni correction was applied for multiple comparisons.
Postoperative early scans (6.9+/- 0.9 days) showed a reduction of blood flow in the both sides of the sternum compared with the preoperative scans (p<0.001). In full-RITA group, there was no significant difference between left and right hemi-sternum (0.56+/- 0.04 and 0.55+/- 0.02 respectively). However, in mid-RITA and non-RITA groups, right hemi-sternum showed significantly better vascularity than left hemi-sternum in the early postoperative period (p<0.001). Three patients (6.6%) with diabetes mellitus in full-RITA group had sternal infection; one of them was deep sternal infection with dehiscence. In mid-RITA group, there was only two patients who had superficial infection (4.4%) and in non-RITA group there was no infection (p=0.234).
Mid-RITA harvesting technique can be preferred to preserve sternal vascularity better than conventional technique. By improving new techniques and methods, more acceptable sternal complications could be achieved than full-RITA technique.
No preview · Article · Feb 2009 · Anadolu kardiyoloji dergisi: AKD = the Anatolian journal of cardiology
[Show abstract][Hide abstract] ABSTRACT: Amaç: Brusella Akdeniz ve Orta Doğu ülkelerinde, aynı zamanda Türkiye'de sıklıkla görülür. Doğal kapak endokarditli 13 olgunun tıbbi ve cerrahi olarak başarı ile tedavisini bildirmektir. Gereç ve Yöntemler: On üç olgu Brusella endokarditi (BE) tanısı ile kliniğimize başvurdu. Tanı Brusella altiplerinin izolasyonu veya antikor varlığı ile doğrulandı. Preoperatif antibiyotik tedavisini takiben mitral kapak dokusunu da içeren genişletilmiş doku debridmanı ile birlikte mitral kapak replasmanı uygulandı. Olgular, Brusella titreleri, kan kültürleri, ekokardiyografi ve taburculuk sonrası antibiyotik tedavisinin devamı ile takip edildi. Bulgular: Başvuru sırasında tüm olgularda ateş mevcuttu ve çoğunlukla dispneikti. Kan testleri, artmış ESH/CRP ve serolojik testler dışında normaldi. BE tanısı serolojik olarak doğrulandıktan sonra, antibiyotik tedavisi verildi. On bir olguya rifampisin, doksisiklin ve trimetoprim/sülfametoksazol (TMP-SMZ); 1 olguya rifampisin, streptomisin ve doksisiklin kombinasyonu; bir hastaya rifampisin, tetrasiklin ve TMP-SMZ uygulandı. Endokarditten etkilenen mitral kapak lifletlerin çoğunluğunda doku kaybı vardı ve tüm olgularda vejetasyon mevcuttu. Mitral kapak replasmanları, hem biyolojik hem de mekanik kapaklar ile uygulandı. Operasyon öncesi başlanan antibiyotik tedavisi ortalama 101.2 ± 16.9 gün uygulandı. Sonuç: Mitral kapakta gelişen BE'nin morbidite ve mortalitesi uygun medikal ve cerrahi yaklaşımla azaltılabilir. Radikal debridman ile birlikte mitral kapak replasmanı tedavinin en önemli parçasıdır ve etkin preoperatif ve uzun dönem postoperatif medikal tedavi ile desteklenmelidir.