Positive Heparin/PF4 Antibodies and High Mortality Rate: a Retrospective Case-Series Analysis

Introduction

Heparin-induced thrombocytopenia (HIT) is a potentially lethal complication of unfractionated or low-molecular weight heparin therapy. We aimed to determine the incidence and mortality rate of patients with positive heparin/platelet factor 4 (PF4) antibodies, which is a rapid detection test of HIT.

Methods

Coronary artery bypass grafting and mitral and aortic valve surgeries were evaluated. Cardiopulmonary bypass was employed in all patients. The diagnosis of HIT was based on immunological assays. Postoperative complications, mortality rates, and the causes of death were specified in patients with positive heparin/PF4 antibodies.

Results

Postoperative thrombocytopenia was detected in 257 patients. Twenty of these patients undergoing open heart surgery were included in the final analysis. Antibodies against heparin/PF4 complex were positive in 20 patients. The mean body mass index was 28.8±2.3 kg/m², mean value of left ventricular ejection fraction was 48.3±6.7%, cardiopulmonary bypass time was 113.0±35.0 min, aortic cross-clamping time was 88.0±32.7 min, mean intensive care unit length of stay was 10.9±4.9 days, mean preoperative platelet count was 307.250±88528 platelets/microliter, and mean postoperative platelet count was 243.050±89.354 platelets/microliter. The mean duration of heparin exposure was 6.9±2.9 days. The mortality rate was 45% (nine patients) and 1.2% (three patients) in heparin/PF4 complex positive and negative patients, respectively.

Conclusion

Although the incidence of HIT was low in patients undergoing open heart surgery, an increased rate of early mortality was observed in patients with positive heparin/PF4 antibodies.

Long Term Outcomes of Freestyle Stentless Aortic Bioprosthesis: A Single Center Experience

Background: The study is presenting our long-term clinical results after freestyle stentless aortic root bioprosthesis replacement in patients with severe aortic insufficiency with ascending aortic aneurysm. Methods: Seventy-seven patients with ascending aortic aneurysms and aortic valve insufficiency underwent a total root replacement procedure using a stentless “Freestyle” valve (Medtronic Inc., Minneapolis, Minnesota). There were 50 (64.9%) men and 27 (35.1%) women. Mean age was 68.7 ± 11.1 years. The surgical procedure used a complete root replacement. Concomitant procedures included coronary artery bypass grafting in 15 (19.5%) patients. Results: The mean cardiopulmonary bypass time was 130.3 ± 26.4 minutes and total aortic cross clamp time was 99.5 ± 23.6 minutes. Hospital mortality was 2.6%. The median follow-up time was 11.2 years. The 5- and 10-years freedom from aortic valve reoperation were 97.4 ± 1.2% and 93.4 ± 4.9%, respectively. During 10 years follow up, there were 14 late deaths; 4 deaths were cardiac, and 10 deaths were noncardiac. Valve-related deaths were attributable to thromboembolism in 1 patient, endocarditis in 2 patients, and congestive heart failure in 1 patient. Conclusion: The freestyle stentless aortic root bioprosthesis offered good clinical outcomes, in terms of survival and structural valve deterioration. The Freestyle valve is a viable option for use in patients undergoing bioprosthetic aortic valve replacement and expected desire for long-term durability.

Second recurrence of familial atrial myxomas: mother and daughter simultaneously

Sporadic ca rdiac myxomas rarely recur, however recurrence rates are higher in patients with a familial aggregation or Carney complex. Carney complex is characterised by multiple mucocutaneous lesions and accounts for up to two-thirds of familial cardiac myxomas. A second recurrence is very rare, even in the case of Carney complex. We report on two cases of recurrent cardiac myxoma, a mother and daughter, who concurrently presented with a second recurrence of atrial myxomas. The time interval between the first and second recurrence following surgery was four years in both. The possibility of repeat recurrence of cardiac myxomas demonstrates the importance of regular echocardiography to detect recurrence and to prevent the potential complications associated with cardiac myxomas. Family screening should be recommended for familial myxomas.

Pain and the Quality of Life Following Robotic Assisted Minimally Invasive Surgery

OBJECTIVE

Minimally invasive bypass grafting is a promising surgical treatment in proximal LAD stenosis procedures. The main goal of this study was to make comparisons between robotically assisted minimally invasive coronary bypass surgery and conventional surgery in isolated proximal LAD lesions in terms of pain and quality of life improvement.

METHODS

The study contains patients with proximal LAD lesions who were treated with robotically assisted minimally invasive coronary artery bypass surgery and conventional bypass surgery between June 2005 and November 2012. Fifty patients treated with coronary bypass with cardiopulmonary bypass and complete sternotomy were categorized as Group 1. Fifty patients who applied for robotically assisted minimally invasive bypass surgery were categorized as Group 2. The evaluations of pain and quality of life were done according to the Verbal Rating Scale (VRS) and SF-36 health survey questionnaire, respectively.

RESULTS

The conventional bypass group and robotic group had 4.8 ± 1.9 years and 4.3 ± 1.6 years mean follow-up time, respectively. The robotic bypass group had a significantly shorter ICU stay and hospital stay than the conventional bypass group (P < .05). The pain score was higher in the robotic bypass group on the 1st postoperative day (P < .05), but the score on the 4th postoperative day was higher in the conventional bypass group (P < .05). In terms of domains of the SF-36 questionnaire, patient scores were significantly higher in patients who were operated with robotically assisted minimally invasive direct coronary artery bypass (MIDCAB) procedure than in patients who were operated with conventional bypass technique.

CONCLUSION

Patients operated with robotically assisted MIDCAB procedure had results with lesser pain, shorter ICU stay, and shorter hospital stay than the other group in isolated proximal LAD stenosis. The same group also had better quality of life results according to the SF-36 questionnaire results.

The Comparison between Minimally Invasive Coronary Bypass Grafting Surgery and Conventional Bypass Grafting Surgery in Proximal LAD Lesion

<strong>Background</strong>: Minimally invasive bypass grafting surgery has entered the clincal routine in several centers around the world, with an increasing popularity in the last decade. In our study, we aimed to make a comparison between minimally invasive coronary artery bypass grafting surgery and conventional bypass grafting surgery in isolated proximal left anterior descending artery (LAD) lesions. <br /><strong>Methods</strong>: Between January 2004 and December 2011, patients with proximal LAD lesions, who were treated with robotically assisted minimally invasive coronary artery bypass surgery and conventional bypass surgery, were included in the study. In Group 1, coronary bypass with cardiopulmonary bypass and complete sternotomy were applied to 35 patients and in Group 2, robotically assisted minimally invasive bypass surgery was applied to 35 patients. The demographic, preoperative, perioperative, and postoperative data were collected retrospectively.<br /><strong>Results</strong>: The mean follow-up time of the conventional bypass group was 5.7 ± 1.7 years, whereas this ratio was 7.3 ±1.3 in the robotic group. There was no postoperative transient ischemic attack (TIA), wound infection, mortality, or need for intra-aortic balloon pump (IABP) in any of the patients. In the conventional bypass group, blood transfusion and ventilation time were significantly higher (P &lt; .05) than in the robotic group. The intensive care unit (ICU) stay and hospital stay were remarkably shorter in the robotic group <br />(P &lt; .01). The postoperative pneumonia rate was significantly higher (20%) in the conventional bypass group <br />(P &lt; .01). Postoperative day 1 pain score was higher in the robotic group (P &lt; .05), however, postoperative day 3 pain score in the conventional bypass group was higher (P &lt; .05). Graft patency rate was 88.6% in the conventional bypass group whereas this ratio was 91.4% in the robotic bypass group, which was not clinically significant (P &gt; .05).<br /><strong>Conclusion</strong>: In isolated proximal LAD stenosis, robotic assisted minimally invasive coronary artery bypass grafting surgery requires less blood products, is associated with shorter ICU and hospital stay, and lesser pain in the early postoperative period in contrast to conventional surgery. The result of our studies, which showed similarities to the past studies, lead us to recognize the importance of minimally invasive interventions and the need to perform them more frequently in the future.

Hybrid vascular surgery approaches for multilevel arterial occlusive disease

BACKGROUND

The incidence of multilevel vascular occlusive disease is increased with patient age. Multilevel arterial occlusive disease cases are some of the hardest in the vascular surgical realm because of the comorbidities. In these high-risk patients inflow constrictions may limit the success of distal bypasses. At the same time the constrictions in the outflow may necessitate long bypass circuits that have less long-term patency rates.

METHODS

Our study included 38 patients with multilevel arterial occlusive disease to whom hybrid vascular approaches were applied between January 2005 and December 2011 in Şişli Florence Nightingale Hospital. The patient group had a mean age of 68.1 (48-98) and included 29 male (89%) and 9 female (11%) patients. Complaints were claudication under 100 meters of walking in 19 patients (50%), resting pain in 14 patients (36%), and disturbed tissue integrity in 5 patients (14%). Mean in-hospital stay was calculated to be 6.4 days (4-15). In one patient (2.6%), a second procedure was necessary due to graft thrombosis and this case resulted in amputation under the level of the knee. Minor toe amputations in a second session were applied to 5 patients (14%) with symptoms of foot sores. Wound infections occurred in two patients (5%) and were treated with antibiotherapy and wound care.

RESULTS

At the end of the follow-up time, extremity survival was found to be 94.1%.

CONCLUSIONS

In the treatment of multilevel peripheral arterial occlusive disease, a hybrid approach is a treatment option which is less invasive and sufficient.

Rapid Detection of Acute Kidney Injury by Urinary Neutrophil Gelatinase-Associated Lipocalin in Patients Undergoing Cardiopulmonary Bypass

OBJECTIVE

Acute kidney injury (AKI) is common following cardiopulmonary bypass (CPB). The aim of this study is to determine the accuracy of urinary neutrophil gelatinase-associated lipocalin (NGAL) levels following cardiac surgery to establish the severity of renal impairment as compared to serum creatinine levels.

METHODS

A total number of 28 patients undergoing elective cardiopulmonary bypass were included. Diagnostic criteria of AKI was established in case of a percentage increase in serum creatinine concentration of >50%. Serum creatinine levels were recorded in the preoperative period before induction and in the postoperative period at 24, 48, and 72 hours. Urinary NGAL measurement was performed before induction and in the 4(th) postoperative hour. The duration of CPB surgery, hospital stay, and cross-clamp time were recorded.

RESULTS

Based on AKI criteria, subjects were grouped as AKI (n=11) and no AKI (n=19). Postoperative urinary NGAL levels were significantly higher in the group with AKI (11.8 ng mL(-1) vs. 104.0 ng mL(-1), p=0.003). In the AKI group, CPB time bypass (111.9 min vs. 82.7 min) and cross-clamp time (76.9 min vs. 59.1 min) were significantly higher. A cut-off of 25.5 ng mL(-1) yielded a sensitivity of 81.82% and a specificity of 94.12% at the postoperative 4(th) hour with an AUC of 0.947 for predication of AKI.

CONCLUSION

Urine NGAL rose significantly much earlier as compared to serum creatinine levels in the early postoperative period. Although larger case series are needed, we are of the opinion that urinary NGAL measurements may be used as an early clinical marker of AKI following CPB.

Pharmacotherapeutic agents used in temporomandibular disorders

Depending on the source and character, pharmacotherapy is one of the most commonly used methods to treat temporomandibular disorders in addition to the use of appliances, physiotherapy, behavioral therapy, and surgical interventions. To decide on the appropriate treatment approach for the treatment of temporomandibular disorders, pharmacotherapeutics should be understood in great detail. As for other pain treatments, pharmacotherapy can be used as a monotherapy or combined with other treatment options in temporomandibular disorders. The aim of the present review is to overview the primary analgesics and myorelaxants used in temporomandibular disorders.

Left atrial myxoma with neovascularization presenting as a sick sinus syndrome

Myxoma is benign tumor of the heart. It is mostly located in the left atrium and revascularized by the left and right coronary artery in 30% to 40% of cases. Symptoms of these neovascularized cardiac myxomas are typically quite variable, from obstruction of mitral valve to coronary embolism resulting in acute myocardial infarction. In this case, left atrial myxoma that is revascularized by nodal branches of the right coronary artery presented as a sick sinus syndrome, which is rare in literature.

[Left ventricular mass regression after aortic valve replacement]

OBJECTIVE

Our objective was to evaluate the degree of change in left ventricular mass index (LVMI) regression after aortic valve replacement (AVR) using three different valves.

METHODS

Group 1 (n=17) included patients with bioprosthesis (Medtronic Hancock 2), Group 2 (n=21) included patients with mono-leaflet mechanical valve (Medtronic Hall), and Group 3 (n=17) included patients with bi-leaflet mechanical valve (St Jude). The mean ages of Group 1, 2 and 3 patients were 70.8±9.1, 61.6±13.7 and 56.2±18.3 years, respectively. In this observational study, patients were followed-up after surgery and left ventricular wall thickness and valvular functions were evaluated with echocardiography. The findings were compared with preoperative values. Statistical analyses were performed using one-way variance analysis (ANOVA), Kruskal -Wallis, and Chi-square tests.

RESULTS

Statistically significant difference was observed among the three groups with respect to age (p=0.015). LVMI regressed in all groups; Group 1 from 232.74±53.36 g/m² (preoperative) to 174.64±46.33 g/m² (postoperative) (p=0.0001), Group 2-from 198.49±40.53 g/m2 to 167.04±33.9 g/m² (p=0.0001), and Group 3-228.77±47.87 g/m² to 185.44±37.76 g/m² (p=0.0001). No statistically significant difference was observed among the groups with respect to LVMI regression (p=0.054, p=0.363).

CONCLUSION

Mid-term results of AVR with three different aortic valve prosthesis revealed that all groups showed a similar regression of left ventricular mass. However, we advocate that long-term results of an increased number of patients should be evaluated for assessment in depth.

Video-Assisted Bilateral Epicardial Pulmonary Vein Isolation for the Treatment of Lone Atrial Fibrillation

BACKGROUND

This paper aims to evaluate the feasibility and the efficacy of a new off-pump, bilateral thoracoscopic pulmonary vein isolation technique in patients with lone atrial fibrillation.

METHODS

Between April 2004 and February 2006, 26 drug-resistant and symptomatic lone atrial fibrillation patients (18 permanent, 8 paroxysmal) underwent an irrigated radiofrequency ablation procedure using the Cardioblate ablation system (Medtronic, Minnesota). There were 16 men and 10 women with a mean age of 55 +/- 11 years. Mean duration of atrial fibrillation was 34.2 +/- 18.9 months. All patients underwent a bilateral thoracoscopic procedure in which both pulmonary veins were ablated with an atrial cuff using an off-pump epicardial approach. The conduction block was assessed by pacing the pulmonary veins after each ablation. Sixteen patients underwent endoscopic stapling of the left atrial appendage.

RESULTS

There were no hospital deaths. All procedures were completed as planned without any conversions to sternotomy. There were no major complications. Follow-up was complete at 6 months, and 80% of the patients were in sinus rhythm (paroxysmal: 100%, permanent: 72%). Of the patients with permanent atrial fibrillation, 85% had regained their atrial transport function. No major thromboembolic event was observed during the follow-up period.

CONCLUSIONS

The video-assisted bilateral pulmonary vein isolation technique was safe and effective. It was curative for paroxysmal atrial fibrillation patients and effective for permanent atrial fibrillation cases. This technique may find wider application if accumulating data further support these findings.

Right coronary revascularization by coronary-coronary bypass with a segment of internal thoracic artery

In certain coronary artery bypass grafting operations, the internal thoracic artery is not by itself adequate for complete arterial revascularization. Which graft should be used for revascularization of the right coronary artery is still a matter of debate. From August 2000 through July 2005, we performed coronary-coronary bypass grafting on 48 patients (77.1% men, 22.9% women), whose mean age was 57.2 years (range, 40-75 yr). After completion of the internal thoracic artery anastomoses, we performed coronary-coronary bypass grafting with a remaining (distal) segment of the left (or, rarely, the full length of the free right) internal thoracic artery. The proximal and distal anastomoses of the internal thoracic artery to the right coronary artery were end-to-side. We preferred to use the right coronary ostium as the proximal anastomosis site where possible; otherwise, we used a disease-free segment of the right coronary artery. A total of 192 anastomoses were performed (mean, 4.15 per patient); all used the bilateral internal thoracic arteries as conduits. There were no in-hospital deaths or perioperative myocardial infarctions. The duration of follow-up ranged from 1 to 46 months (mean, 9.6 mo). Follow-up angiography was performed in 24 patients (50%). The mean time to coronary angiography was 16.5 months (range, 7 days-2 years). The patency rate was 100%. We conclude that coronary-coronary anastomosis by means of a distal segment of the internal thoracic artery can help to achieve complete arterial revascularization in selected patients.

Temporomandibular joint dysfunction syndrome: a close association with systemic joint laxity (the hypermobile joint syndrome)

Sixty-two patients admitted for elective reconstructive surgery of the temporomandibular joint (TMJ) and eight seen as outpatients with a chief complaint of TMJ dysfunction during the same time interval were evaluated for possible etiologic factors contributing to the disease. All hospitalized patients had severe, end-stage degenerative changes within the TMJ, whereas outpatients had less severe disease and did not require surgery. TMJ dysfunction in some patients was said to be a result of established causes including bruxism, malocclusion, and trauma. No patient in this series had evidence of a systemic inflammatory polyarthritis. Of the 70 patients, 38 (54%) met criteria, based on those of Carter and Wilkinson, as modified by Beighton et al., sufficient to warrant a diagnosis of the hypermobile joint syndrome. Five patients had classic Ehlers-Danlos syndrome and therefore were not patients with "benign hypermobility," and an additional two cases were described as "marfanoid" and as possible Ehlers-Danlos syndrome, respectively. Radiographs showed TMJ hyperextensibility in four hypermobile patients. Long-term surgical outcome was identical in the hypermobile and nonhypermobile groups. The incidence of hypermobility in this series is strikingly higher than the expected incidence in an otherwise population. Magnetic resonance images of the TMJs on separate groups of asymptomatic normal and hypermobile women identified excessive anterior movement in the hypermobile group, together with abnormal anterior disk position in some. We hypothesize that hypermobility within the TMJ may cause accelerated disk destruction and degenerative disease.

Systemic joint laxity (the hypermobile joint syndrome) is associated with temporomandibular joint dysfunction

A consecutive series of 37 individuals admitted to the hospital for elective temporomandibular joint (TMJ) reconstructive surgery and 3 seen as outpatients with TMJ disease were evaluated for rheumatic disease or for another etiologic factor that might account for this problem. These 40 patients were screened by history, physical examination, and laboratory study. We soon noticed that many patients had generalized joint laxity. Eighteen of the first 40 individuals satisfied established criteria for the hypermobile joint syndrome. An additional 3 were found to have Ehlers-Danlos syndrome or a forme fruste of this disorder. Many were markedly hypermobile and could perform a number of flexible maneuvers. Although excessive joint laxity is known to be associated with a variety of rheumatic conditions, TMJ disease has not been recognized as one of them. No patient in this series had a systemic inflammatory disorder or any other apparent etiologic factor for TMJ disease. We suggest that there is a cause-and-effect relationship between generalized joint laxity and TMJ disease.

The use of acrylic resin oral prosthesis in radiation therapy of oral cavity and paranasal sinus cancer

In radiation therapy of cancers of the oral cavity and the paranasal sinuses, the extent to which the tissues of the oral cavity are included in the radiation treatment portals will determine the severity of the oral discomfort during treatment. This will affect the nutritional status of the patients, and may eventually affect the total dose of radiation which the patients can receive for treatment of their cancers. In cooperation with the Maxillofacial Prosthetic Department, an acrylic resin oral prosthesis was developed. This prosthesis is easy to use and can be made for each individual patient within 24 hours. It allows for maximum sparing of the normal tissues in the oral cavity and can be modified for shielding of backscattered electrons from heavy metals in the teeth. We have also found that acrylic resin extensions can be built onto the posterior edge of post-maxillectomy obturators; this extension can be used as a carrier for radioactive sources to deliver radiation to deep seated tumor nodules in the paranasal sinuses.

Construction of a buccal flange obturator

There are various methods of fabricating obturators. Cleanliness and simplicity are important considerations in the construction of any intraoral prostheses. With these considerations in mind, construction of the buccal flange obturator has been described.