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Sellke N, Kuczmarski A, Lawandy I, Cole VL, Ehsan A, Singh AK, Liu Y, Sellke FW, Feng J. Enhanced coronary arteriolar contraction to vasopressin in patients with diabetes after cardiac surgery. J Thorac Cardiovasc Surg 2018; 156:2098-2107. [PMID: 30057184 PMCID: PMC6242764 DOI: 10.1016/j.jtcvs.2018.05.090] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 04/10/2018] [Accepted: 05/13/2018] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Cardioplegic arrest (CP) and cardiopulmonary bypass (CPB) are associated with vasomotor dysfunction of coronary arterioles in patients with diabetes (DM) undergoing cardiac surgery. We hypothesized that DM may up-regulate vasopressin receptor expression and alter the contractile response of coronary arterioles to vasopressin in the setting of CP/CPB. METHODS Right atrial tissue samples of patients with DM and without (ND) (n = 8 in each group) undergoing cardiac surgery were harvested before and after CP/CPB. The isolated coronary arterioles (80-150 μm) dissected from the harvested right atrial tissue samples were cannulated and pressurized (40 mm Hg) in a no-flow state. The changes in diameter were measured with video microscopy. The protein expression/localization of vasopressin 1A receptors (V1A) and vasopressin 1B receptors (V1B) in the atrial tissue were measured by immune-blotting and immunohistochemistry. RESULTS The pre-CP/CPB contractile responses of the coronary arterioles to vasopressin were significantly increased post-CP/CPB in both the ND and DM groups. This effect was more pronounced in the vessels from patients in the DM group than that of vessels from patients in the ND group (P < .05). Vasopressin-induced contractile response of the coronary arterioles was inhibited in the presence of the specific V1A antagonist SR 49059 (10-7 M) in both ND and DM vessels (P < .05). The post-CP/CPB protein levels of V1A were significantly increased compared with pre-CP/CPB values in both the ND and DM groups (P < .05), whereas this increase was greater in DM than that of ND (P < .05). Immunohistochemistry staining further indicates that V1B were mainly expressed in the myocardium but not in vascular smooth muscle. CONCLUSIONS CP/CPB and DM are both associated with up-regulation in V1 receptor expression/localization in human myocardium. Vasopressin may induce coronary arteriolar constriction via V1A. This alteration may lead to increased coronary arteriolar spasm in patients with DM undergoing CP/CPB and cardiac surgery.
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Affiliation(s)
- Nicholas Sellke
- Division of Cardiothoracic Surgery, Department of Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI
| | - Alex Kuczmarski
- Division of Cardiothoracic Surgery, Department of Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI
| | - Isabella Lawandy
- Division of Cardiothoracic Surgery, Department of Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI
| | - Victoria L Cole
- Division of Cardiothoracic Surgery, Department of Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI
| | - Afshin Ehsan
- Division of Cardiothoracic Surgery, Department of Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI
| | - Arun K Singh
- Division of Cardiothoracic Surgery, Department of Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI
| | - Yuhong Liu
- Division of Cardiothoracic Surgery, Department of Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI
| | - Frank W Sellke
- Division of Cardiothoracic Surgery, Department of Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI
| | - Jun Feng
- Division of Cardiothoracic Surgery, Department of Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI.
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Crestanello JA. Vasopressin atrial coronary constriction in humans: The unknown clinical significance of a laboratory finding. J Thorac Cardiovasc Surg 2018; 156:2108-2109. [PMID: 30057186 DOI: 10.1016/j.jtcvs.2018.05.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 05/29/2018] [Accepted: 05/31/2018] [Indexed: 11/29/2022]
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Microvascular dysfunction in patients with diabetes after cardioplegic arrest and cardiopulmonary bypass. Curr Opin Cardiol 2018; 31:618-624. [PMID: 27652811 DOI: 10.1097/hco.0000000000000340] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE OF REVIEW The purpose of the current review is to describe the changes of microvascular function in patients with diabetes after cardioplegic arrest and cardiopulmonary bypass (CPB) and cardiac surgery. RECENT FINDINGS Cardiac surgery, especially that involving cardioplegia and CPB, is associated with significant changes in vascular reactivity of coronary/peripheral microcirculation, vascular permeability, gene/protein expression, and programmed cell death, as well as with increased morbidity and mortality after surgical procedures. In particular, these changes are more profound in patients with poorly controlled diabetes. SUMMARY Because alterations in vasomotor regulation are critical aspects of mortality and morbidity of cardioplegia/CPB, a better understanding of diabetic regulation of microvascular function may lead to improved postoperative outcomes of patients with diabetes after cardioplegia/CPB and cardiac surgery.
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Bomberg H, Groesdonk HV, Raffel M, Minko P, Schmied W, Klingele M, Schäfers HJ. Vasopressin as Therapy During Nonocclusive Mesenteric Ischemia. Ann Thorac Surg 2016; 102:813-819. [DOI: 10.1016/j.athoracsur.2016.03.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 01/11/2016] [Accepted: 03/07/2016] [Indexed: 01/24/2023]
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Liguori GR, Kanas AF, Moreira LFP. Managing the inflammatory response after cardiopulmonary bypass: review of the studies in animal models. Braz J Cardiovasc Surg 2014; 29:93-102. [PMID: 24896169 PMCID: PMC4389477 DOI: 10.5935/1678-9741.20140017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 09/24/2013] [Indexed: 11/28/2022] Open
Abstract
Objective To review studies performed in animal models that evaluated therapeutic
interventions to inflammatory response and microcirculatory changes after
cardiopulmonary bypass. Methods It was used the search strategy ("Cardiopulmonary Bypass" (MeSH)) and
("Microcirculation" (MeSH) or "Inflammation" (MeSH) or
"Inflammation Mediators" (MeSH)). Repeated results, human studies,
non-English language articles, reviews and studies without control were
excluded. Results Blood filters, system miniaturization, specific primers regional perfusion,
adequate flow and temperature and pharmacological therapies with anticoagulants,
vasoactive drugs and anti-inflammatories reduced changes in microcirculation and
inflammatory response. Conclusion Demonstrated efficacy in animal models establishes a perspective for evaluating
these interventions in clinical practice.
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Affiliation(s)
- Gabriel Romero Liguori
- Correspondence address: Gabriel Romero Liguori, Instituto do Coração
(InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo,
Av. Dr. Enéas de Carvalho Aguiar, 44 - 2º andar - bloco II - sala 13 - Cerqueira
César, São Paulo, SP, Brazil - Zip code: 05403-000. E-mail:
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Groesdonk HV, Raffel M, Speer T, Bomberg H, Schmied W, Klingele M, Schäfers HJ. Elevated endothelin-1 level is a risk factor for nonocclusive mesenteric ischemia. J Thorac Cardiovasc Surg 2014; 149:1436-42.e2. [PMID: 25623906 DOI: 10.1016/j.jtcvs.2014.12.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 11/17/2014] [Accepted: 12/06/2014] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Nonocclusive mesenteric ischemia may occur after cardiac surgery, commonly in conjunction with the use of cardiopulmonary bypass. Some evidence suggests that endothelin-1 serum levels are increased in patients with mesenteric ischemia, but the association of endothelin-1 and nonocclusive mesenteric ischemia has not been studied. The objective was to investigate whether elevated levels of endothelin-1 could be found in patients exhibiting nonocclusive mesenteric ischemia. METHODS In an observational cohort study, nonocclusive mesenteric ischemia developed in 78 of 865 patients undergoing elective cardiac surgery. Control patients were identified from the cohort through 1:1 propensity score matching. Preoperative and postoperative endothelin-1 serum levels were determined by means of enzyme-linked immunosorbent assay. Odds ratios (with 95% confidence interval) were calculated by logistic regression analyses to determine the risk of endothelin-1 for the development of nonocclusive mesenteric ischemia. RESULTS Patients with nonocclusive mesenteric ischemia had higher preoperative (11.3 vs 9.3 pg/mL; P = .001) and postoperative (15.7 vs 11.1 pg/mL, P < .001) levels of endothelin-1 than the controls. The probability of developing nonocclusive mesenteric ischemia increased with each picogram/milliliter endothelin-1 level preoperatively (odds ratio, 1.29; 95% confidence interval, 1.12-1.49) and each picogram/milliliter postoperatively (odds ratio, 2.04; 95% confidence interval, 1.54-2.72). Receiver operating characteristic analyses showed that elevated endothelin-1 serum levels had a high accuracy to predict nonocclusive mesenteric ischemia (optimal cutoff value of 14.5 pg/mL, area under the curve of 0.77, sensitivity 51%, and specificity 94%). CONCLUSIONS Endothelin-1 seems to predispose patients undergoing cardiac surgery to develop nonocclusive mesenteric ischemia. In addition, it may be a useful marker to identify patients at risk for nonocclusive mesenteric ischemia after cardiac surgery.
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Affiliation(s)
- Heinrich V Groesdonk
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany; Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Medical Center, Homburg/Saar, Germany
| | - Miriam Raffel
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Thimoteus Speer
- Division of Nephrology and Hypertension, Department of Medicine, Saarland University Medical Center, Homburg/Saar, Germany
| | - Hagen Bomberg
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany; Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Medical Center, Homburg/Saar, Germany
| | - Wolfram Schmied
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Matthias Klingele
- Division of Nephrology and Hypertension, Department of Medicine, Saarland University Medical Center, Homburg/Saar, Germany
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany.
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Acute mesenteric ischemia after cardiac surgery: an analysis of 52 patients. ScientificWorldJournal 2013; 2013:631534. [PMID: 24288499 PMCID: PMC3826337 DOI: 10.1155/2013/631534] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 09/08/2013] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE Acute mesenteric ischemia (AMI) is a rare but serious complication after cardiac surgery. The aim of this retrospective study was to evaluate the incidence, outcome, and perioperative risk factors of AMI in the patients undergoing elective cardiac surgery. METHODS From January 2005 to May 2013, all patients who underwent cardiac surgery were screened for participation, and patients with registered gastrointestinal complications were retrospectively reviewed. Univariate analyses were performed. RESULTS The study included 6013 patients, of which 52 (0.86%) patients suffered from AMI, 35 (67%) of whom died. The control group (150 patients) was randomly chosen from among cases undergoing cardiopulmonary bypass (CPB). Preoperative parameters including age (P = 0.03), renal insufficiency (P = 0.004), peripheral vascular disease (P = 0.04), preoperative inotropic support (P < 0.001), poor left ventricular ejection fraction (P = 0.002), cardiogenic shock (P = 0.003), and preoperative intra-aortic balloon pump (IABP) support (P = 0.05) revealed significantly higher levels in the AMI group. Among intra- and postoperative parameters, CPB time (P < 0.001), dialysis (P = 0.04), inotropic support (P = 0.007), prolonged ventilator time (P < 0.001), and IABP support (P = 0.007) appeared significantly higher in the AMI group than the control group. CONCLUSIONS Prompt diagnosis and early treatment should be initiated as early as possible in any patient suspected of AMI, leading to dramatic reduction in the mortality rate.
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Groesdonk HV, Klingele M, Schlempp S, Bomberg H, Schmied W, Minko P, Schäfers HJ. Risk factors for nonocclusive mesenteric ischemia after elective cardiac surgery. J Thorac Cardiovasc Surg 2013; 145:1603-10. [DOI: 10.1016/j.jtcvs.2012.11.022] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Revised: 10/06/2012] [Accepted: 11/06/2012] [Indexed: 02/07/2023]
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Viana FF, Chen Y, Almeida AA, Baxter HD, Cochrane AD, Smith JA. Gastrointestinal complications after cardiac surgery: 10-year experience of a single Australian centre. ANZ J Surg 2013; 83:651-6. [PMID: 23530720 DOI: 10.1111/ans.12134] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2013] [Indexed: 12/16/2022]
Abstract
BACKGROUND Gastrointestinal (GI) complications after cardiac surgery are uncommon, but are associated with high morbidity and mortality as well as significant hospital resource utilization. METHODS We analysed a prospectively collected database containing all adult cardiac surgery procedures performed from July 2001 to March 2011 at Monash Medical Centre and Jessie McPherson Private Hospital. Patients with post-operative GI complications were compared to patients without GI complications who were operated in the same period. RESULTS The incidence of GI complications was 1.1% (61 out of 5382 patients) with an overall 30-day mortality of 33% (versus 3% in the non-GI complication group). The most common complications were GI bleeding, gastroenteritis and bowel ischaemia. Patients who had GI complications were significantly older, had higher incidence of renal impairment, chronic lung disease and anticoagulation therapy and were more likely to be in cardiogenic shock. Emergency procedures, combined coronary artery bypass grafting and valve surgery and aortic dissection cases were more common in the GI complication group. The GI complication group also had higher incidence of return to theatre, renal failure, stroke, septicaemia and multi-organ failure. CONCLUSIONS GI complications after cardiac surgery remain an uncommon but dreadful complication associated with high mortality. Our findings should prompt a high degree of clinical vigilance in order to make an early diagnosis especially in high risk patients. Further studies aiming to identify independent predictors for GI complications after cardiac surgery are warranted.
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Affiliation(s)
- Fabiano F Viana
- Department of Cardiothoracic Surgery, Monash Medical Centre, Clayton, Victoria, Australia.
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Le Guillou V, Tamion F, Jouet I, Richard V, Mulder P, Bessou JP, Doguet F. Mesenteric endothelial dysfunction in a cardiopulmonary bypass rat model: the effect of diabetes. Diab Vasc Dis Res 2012; 9:270-9. [PMID: 22278737 DOI: 10.1177/1479164111434432] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Diabetes is a risk factor for perioperative complications after cardiac surgery. We studied its effects on mesenteric endothelial function in a cardiopulmonary bypass (CPB) model. METHODS Forty Wistar rats were divided into four groups: sham (D-CPB-), cardiopulmonary bypass (D-CPB+), diabetic (D+CPB-) and diabetic that have undergone CPB (D+CPB+). Two samples of mesenteric artery were used for nitric oxide synthase (NOS) Western blot analysis, and two others for assessing contractile response and endothelium relaxations. Nitrite products and tumour necrosis factor-alpha (TNF-α) were assessed as markers of inflammatory response. RESULTS We observed an enhanced contractile response to the α-adrenergic agonist associated with impairment of mesenteric vasorelaxation in D+CPB+ rats. Western immunoblot analysis of D+CPB+ highlighted an additive effect of hyper-expression of inducible NOS. A significantly increased inflammatory response was observed after CPB in diabetic animals. CONCLUSIONS This work confirms the potential deleterious impact of diabetes on the mesenteric endothelium during CPB in cardiac surgery.
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Affiliation(s)
- Vincent Le Guillou
- Department of Thoracic and Cardiovascular Surgery, Rouen University Hospital, France
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Bomberg H, Bierbach B, Flache S, Wagner I, Gläser L, Groesdonk HV, Menger MD, Schäfers HJ. Endothelin and vasopressin influence splanchnic blood flow distribution during and after cardiopulmonary bypass. J Thorac Cardiovasc Surg 2012; 145:539-47. [PMID: 22551769 DOI: 10.1016/j.jtcvs.2012.03.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Revised: 02/13/2012] [Accepted: 03/12/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Gastrointestinal blood flow can be compromised during and after cardiopulmonary bypass. Endothelin has been shown to be involved in the intestinal microcirculatory disturbance of sepsis. The aim of the present study was to analyze the involvement of the endothelin system on intestinal blood flow regulation during cardiopulmonary bypass and the effect of vasopressin given during cardiopulmonary bypass. METHODS A total of 24 pigs were studied in 4 groups (n = 6): group I, sham; group II, ischemia/reperfusion with 1 hour of superior mesenteric artery occlusion; group III, cardiopulmonary bypass for 1 hour; and group IV, 1 hour of cardiopulmonary bypass plus vasopressin administration, maintaining the baseline arterial pressure. All the pigs were reperfused for 90 minutes. During the experiment, the hemodynamics and jejunal microcirculation were measured continuously. The jejunal mucosal expression of endothelin-1 and its receptor subtypes A and B were determined using polymerase chain reaction. RESULTS During cardiopulmonary bypass, superior mesenteric artery flow was preserved but marked jejunal microvascular impairment occurred compared with baseline (mucosal capillary density, 192.2 ± 5.4 vs 150.8 ± 5.1 cm/cm(2); P = .005; tissue blood flow, 501.7 ± 39.3 vs 332.3 ± 27.9 AU; P = .025). The expression of endothelin-1 after cardiopulmonary bypass (3.2 ± 0.4 vs 12.2 ± 0.8 RQ, P = .006) and endothelin subtype A (0.7 ± 0.2 vs 2.4 ± 0.6 RQ; P = .01) was significantly increased compared to the sham group. Vasopressin administration during cardiopulmonary bypass led to normal capillary density (189.9 ± 3.9 vs 178.0 ± 6.3; P = .1) and tissue blood flow (501.7 ± 39.3 vs 494.7 ± 44.4 AU; P = .4) compared with baseline. The expression of endothelin-1 (3.2 ± 0.4 vs 1.8 ± 0.3 RQ; P = .3) and endothelin subtype A (0.7 ± 0.2 vs 0.9 ± 0.2 RQ; P = .5) was not different from the sham group. CONCLUSIONS Cardiopulmonary bypass leads to microvascular impairment of jejunal microcirculation, which is associated with the upregulation of endothelin-1 and endothelin subtype A. The administration of vasopressin minimizes these cardiopulmonary bypass-associated alterations.
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Affiliation(s)
- Hagen Bomberg
- Department of Thoracic and Cardiovascular Surgery, University Hospital of Saarland, Homburg/Saar, Germany
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Rodriguez R, Robich MP, Plate JF, Trooskin SZ, Sellke FW. Gastrointestinal Complications following Cardiac Surgery: A Comprehensive Review. J Card Surg 2010; 25:188-97. [DOI: 10.1111/j.1540-8191.2009.00985.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Abboud B, Daher R, Sleilaty G, Madi-Jebara S, El Asmar B, Achouch R, Jebara V. Is prompt exploratory laparotomy the best attitude for mesenteric ischemia after cardiac surgery? Interact Cardiovasc Thorac Surg 2008; 7:1079-83. [PMID: 18815161 DOI: 10.1510/icvts.2008.176271] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Mesenteric ischemia following cardiac surgery is a life-threatening complication. Early identification of patients may help optimizing management and improving outcome. Between January 2000 and July 2007, surgical exploration was realized when mesenteric ischemia was suspected after coronary-artery bypass grafts (CABG). Patients were divided in two groups according to diagnosis confirmation upon laparotomy. Peri-operative predictors of complication and death were analyzed. Of 1634 consecutive patients, 13 (0.8%) developed acute abdomen with suspicion of mesenteric ischemia. Seven (0.4%) underwent resection for ischemic lesions (group 1), of whom two were during a second look laparotomy. The other six patients had normal bowel (group 2). Both groups were comparable according to preoperative status, clinical signs, biological and radiological findings. Delays to laparotomy were 13.7+/-19.0 and 51.4+/-29.0 h in group 1 and 2, respectively (P=0.02). Mortality rates were 46.1% (6/13) overall, 42.8% for group 1 and 50% for group 2. All deaths occurred within the first nine postoperative days. Mesenteric ischemia following CABG is a fatal complication in almost half the cases. Diagnostic tools and timely laparotomy still need to be optimized. Low threshold-based strategy for prompt surgical intervention is efficient for both diagnosis and treatment.
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Affiliation(s)
- Bassam Abboud
- Department of General Surgery, Hotel Dieu de France Hospital, Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon.
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