Comparison of Bretschneider HTK cardioplegia solution and blood cardioplegia in terms of postoperative results in patients who underwent isolated supracoronary ascending aortic replacement

INTRODUCTION

Cardiac arrest with cardioplegia is the most common and reliable method of myocardial protection in cardiac surgery, but there is no definite consensus on the use of different types of cardioplegia. Two of the commonly used types of cardioplegia are Bretschneider histidine-tryptophan-ketoglutarate solution (Custodiol) and conventional blood cardioplegia. In this study, Custodiol solution and conventional blood cardioplegia used in patients with type A aortic dissection who underwent supracoronary ascending aortic replacement were aimed to be compared in terms of postoperative results.

METHODS

70 patients with type A aortic dissection who underwent supracoronary ascending aortic replacement in our clinic between January 2011 - October 2020 were included. Patients were divided into two groups, blood cardioplegia group (n = 48) and Custodiol group (n = 22) and they were compared regarding preoperative, perioperative and postoperative variables.

RESULTS

There was no significant difference between cardiopulmonary bypass time and cross-clamp time (p = 0.17 and p = 0.16, respectively). Mechanical ventilator weaning time, intensive care unit stay and hospital stay were shorter in Custodiol group (p = 0.04,p = 0.03 and p = 0.05, respectively). While inotropic support need was higher in the blood cardioplegia group (p = 0.001), there was no significant difference in terms of mortality, arrhythmia, neurological complications and renal complications.

CONCLUSIONS

Our results show that Custodiol cardioplegia solution may be superior to blood cardioplegia in reducing mechanical ventilation weaning period, intensive care and hospital stay, and reducing the use of inotropic agents in patients with type A aortic dissection undergoing supracoronary ascending aorta replacement.

Reliability of Ellman Classification System in Partial Thickness Rotator Cuff Tears on Magnetic Resonance Views

PURPOSE OF THE STUDY The current study aimed to investigate the intra- and inter-observer reliability of the Ellman classification system in partialthickness rotator cuff tears through magnetic resonance imaging (MRI) scans instead of arthroscopic views. MATERIAL AND METHODS Pre-operative MRI scans of 45 patients, with confirmed partial-thickness rotator cuff rupture in previous arthroscopic surgeries (performed by the senior author), were obtained from Picture Archiving and Communication Systems records. The observers (n=8) were asked to categorize MRI scans according to Ellman's classification of location and grade. There were four orthopedic surgeons less experienced in rotator cuff operations in the first group and four more experienced orthopedic surgeons in the second group. They were asked to re-evaluate the MRI scans six weeks later, without access to their previous answers. Reliability evaluation was performed within and among the groups. It was also evaluated if the surgeon's experience increased the reliability of the classification. Fleiss kappa coefficient was used for the inter-observer reliability and Cohen kappa coefficient for the intra-observer reliability, and post hoc analysis was performed. RESULTS When all observers were examined in the inter-observer evaluation, it was seen that there was moderate agreement in the first location evaluation (κ=0.414); however, there was fair agreement in all other evaluations in both groups (κ=0.339- 0.383-0.337, respectively). When all observers were examined in the mean intra-observer evaluation, it was seen that there was substantial agreement in both evaluations (κ=0.795-0.721, respectively). DISCUSSION A classification system must be valid, reliable, and reproducible. It should establish a standard terminology for both surgeons and researchers. The correct identification of the tear configuration is crucial for selecting the correct repair technique. In our study, in which we evaluated the Ellman classification, which is frequently used in arthroscopic diagnosis, we investigated its intra-observer and inter-observer reliability on MRI scans. Although the mean intra-observer evaluation results were substantial agreement (κ=0.795-0.721, respectively), inter-observer evaluation results were fair agreement (κ=0.339- 0.383-0.337, respectively) except for the first location evaluation (κ=0.414). CONCLUSIONS Although intra-observer reliability was satisfactory, the Ellman system used in the classification of partial-thickness rotator cuff tears was not found to be useful by using only MRI views because of fair inter-observer reliability except for the first location evaluation, which was moderate agreement. Key words: partial, rotator cuff, tear, Ellman classification, reliability, validity.

Direct kidney injury or lower extremity ischemia induced indirect kidney injury: Which one is more harmful for kidneys?

OBJECTIVES

The aim of this study was to investigate and compare the severity of kidney damage following lower limb ischemia-reperfusion and direct kidney ischemia-reperfusion.

METHODS

Thirty Sprague Dawley male rats were randomly divided into three groups; lower extremity ischemia-reperfusion group (Group 2), renal ischemia-reperfusion group (Group 3) and control (anesthesia and median laparotomy only) (Group 1). In group 3, 1-h ischemia was performed on the kidney and in group 2, 1-h ischemia was performed on the left lower extremity. This procedure was followed by reperfusion for 24 h. Renal tissues were removed after the reperfusion period and the groups were evaluated for glutathioneperoxidase activity, malondialdehyde and GSH levels, and furthermore, their histolopathological scores were calculated.

RESULTS

Renal malondialdehyde levels were significantly higher in Group 2 and Group 3 than they were in the Control group. There was no significant difference in renal malondialdehyde levels between Group 2 and Group 3. Kidney glutathione (GSH) levels were statistically lower in Group 2 and Group 3 than in the Control group. No statistically significant difference was found between Group 2 and Group 3 regarding their GSH levels. In histological evaluation, there was no statistically significant difference between Group 2 and Group 3 in terms of kidney damage score.

CONCLUSIONS

This study has identified that lower extremity ischemia induces remote kidney damage with similar features to kidney injury, occurring after direct kidney ischemia-reperfusion.

Histopathologic Evaluation of COVID-19 Patients With Peripheral Arterial Thromboembolism: Does Clot Composition Make Any Sense?

BACKGROUND

Coronavirus disease 2019 (COVID-19) causes thromboembolic complications during or post-infection period despite a lack of conventional risk factors. The study aims to learn fundamental changes in COVID-19 patients who underwent embolectomy in terms of clinical characteristics and clot composition.

METHODS

In a retrospective cohort study design, we evaluated 21 patients who underwent embolectomy in our clinic between March 12, 2020, and December 31, 2020. Demographics, characteristics, and laboratory values were abstracted and analyzed. Histopathological assessment was held in the pathology department.

RESULTS

Of these 21 patients, 11 (52.3%) were SARS-CoV-2 positive and 10 (47.6%) were SARS-CoV-2 negative. There is no statistical difference in terms of anatomic distribution, diagnostic method, length of hospital stay, amputation or mortality levels. Thromboembolic material of COVID-19 patients include significantly less red blood cell (RBC) (21.2-32.6%; P= 0.01), more lymphocyte (14.1-2.6%; P< 0.001), and more leukocyte (27.1-22.1%; P= 0.05). There was no statistical difference between the fibrin ratio.

CONCLUSIONS

Inflammatory cells are prominent in arterial thromboembolic material of COVID-19 patients. A combination of hyperinflammation and prothrombotic status may be responsible for this phenomenon.

The effect of bovine serum albumin-glutaraldehyde and polyethylene glycol polymer on neointimal hyperplasia in rabbit carotid artery anastomosis

OBJECTIVE

Since the systemic drugs have been used to reduce the hyperplasic response in the tunica intima, the periadventitial local drug applications to the vascular wall have gained more popularity. In this study, we investigated the effect of bovine serum albumin-glutaraldehyde and polyethylene glycol polymer on neointimal hyperplasia in rabbit carotid artery anastomosis to explore the effects of these two different agents.

METHODS

21 New Zealand male rabbits were randomly divided into three groups. The carotid artery transection and anastomosis was performed onthe control group. The bovine serum albumin-glutaraldehyde and the polyethylene glycol polymer were applied locally on the other two groups seperatley after transection and anastomosis of the carotid arteries. At the end of 28-day follow-up, the histological and the immunohistochemical results related to neointimal hyperplasia were compared.

RESULTS

The glue residues were detected in the BSA-glutaraldehyde group, but in the PEG polymer group there was no glue residue. The intima thickness and the intima/media thickness ratio in the control group was significantly higher (p<0.05) than the other groups. These values did not differ significantly between the BSA-glutaraldehyde group and the PEG polymer group (p>0.05). The lumen diameter and the area in the control group were significantly higher (p < 0.05) than the BSA-glutaraldehyde group. These values between the control group and the PEG polymer group did not differ significantly (p>0.05). aSMA-positive staining score in the Control group was found to be significantly lower (p < 0.05) than the BSA-glutaraldehyde and PEG polymer group and the VEGF-positive staining score in the control group was found to be significantly higher (p < 0.05) than the BSA-glutaraldehyde and the PEG polymer group.

CONCLUSIONS

Although the both agents have positive results on neointimal hyperplasia, it would be favorable to use polyethylene glycol polymer, since it does not seem to affect the lumen area and the lumen diameter of the vessel.

Surgical Management of Left Sinus of Valsalva Aneurysm Presenting with Exertional Chest Pain

Left sinus of Valsalva aneurysm (SVA) is a very infrequent clinical entity. Valsalva aneurysms are often asymptomatic in right and non-coronary sinuses and the diagnosis is often incidental. A left SVA which presents with exertional chest pain due to compression of left coronary system arteries is extremely rare. In this case, we present a successful surgical repair of left SVA without aortic regurgitation or myocardial infarction in a 59-year-old male patient.

Comparison of Femoral and Axillary Artery Cannulation in Acute Type A Aortic Dissection Surgery

INTRODUCTION

One of the most important points of the acute type A aortic dissection surgery is how to perform cannulation regarding cerebral protection concerns and the conditions of arterial structures as a pathophysiological consequence of the disease.

OBJECTIVE

In this study, femoral and axillary cannulation methods were compared in acute type A aortic dissection operations.

METHODS

The study retrospectively evaluated 52 patients who underwent emergency surgery for acute type A aortic dissection. Patients without malperfusion according to Penn Aa classification were chosen for preoperative standardization of the study groups. The femoral arterial cannulation group was group 1 (n=22) and the axillary arterial cannulation group was group 2 (n=30). The groups were compared in terms of perioperative and postoperative results.

RESULTS

There was no statistically significant difference in terms of preoperative data. In terms of postoperative parameters, especially early mortality and new-onset cerebrovascular event, there was no statistically significant difference. Mortality rates in group 1 and group 2 were 13.6% (n=3) and 10% (n=3), respectively (P=0.685). Postoperative new-onset cerebral events ratio was found in 5 (22.7%) in the femoral cannulation group and 6 (20%) in the axillary cannulation group (P=0.812).

CONCLUSION

Both femoral and axillary arterial cannulation methods can be safely performed in patients with acute type A aortic dissection, provided that cerebral protection strategies should be considered in the first place. The method to be performed may vary depending on the patient's current medical condition or the surgeon's preference.

Which Distant Organ is Most Affected by Lower Extremity Ischemia-Reperfusion?

BACKGROUND

It has been experimentally shown that reperfusion injury occurs in many remote organs after ischemia-reperfusion (I/R) of the lower extremity. However, which distant organ is affected more after I/R of the lower extremity has not been investigated. In this study, we investigate which remote organ is predominantly affected after lower extremity I/R.

METHODS

Twenty male Sprague-Dawley rats were randomly divided into 2 groups: sham (group 1) and lower extremity I/R (group 2). In group 2, 1 hr of ischemia of the left lower extremity was followed by 24 hr of reperfusion of the limb. After reperfusion, the lung, liver, kidney, heart, and small intestine tissues were harvested in both groups.

RESULTS

In the I/R group, the malondialdehyde levels were significantly higher in the heart and small intestine tissues than those in other tissues (P < 0.05). In addition, in the I/R group, the glutathione and glutathione peroxidase activities were also higher in the heart tissues than those in other tissues (P < 0.05). However, these results were not significant because the malondialdehyde, glutathione, and glutathione peroxidase levels of the heart tissues in the control group were higher than those of the other tissues. Therefore, no statistically significant difference was found between the tissues in terms of the histological damage score we created and the terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling-positive cell numbers.

CONCLUSIONS

There was no difference in the severity of reperfusion injury between the tissues we examined after lower extremity I/R. This suggests that every distal organ should be carefully monitored after lower extremity I/R.

"Overtime Hours Effect" on Emergency Surgery of Acute Type A Aortic Dissection

Objective

Treatment of acute diseases of the aorta is still associated with high mortality and morbidity. It is believed that interventions for these diseases on overtime hours (night shifts or weekend shifts) may increase mortality. In this study, we investigated the effect of performing acute type A aortic dissection surgery on overtime hours in terms of postoperative outcomes.

Methods

206 patients who underwent emergency surgery for acute type A aortic dissection were retrospectively evaluated. Two groups were constituted: patients operated on daytime working hours (n=61), and patients operated on overtime hours (n=145), respectively.

Results

Chronic obstructive pulmonary disease and repeat surgery were higher in group 1. There was no statistically significant difference between the two groups in terms of operative and postoperative results. Mortality rates and postoperative neurological complications in group 1 were 9.8% and 13.1%, respectively. In group 2, these rates were 13.8% and 12.4%, respectively (P=0.485 - P=0.890). Multivariate analysis identified that cross-clamp time, amount of postoperative drainage, preoperative loss of consciousness and postoperative neurological complications are the independent predictors of mortality.

Conclusions

As the surgical experience of the clinics improves, treatment of acute type A aortic dissections can be successfully performed both overtime and daytime working hours.

Inflammation, Atrial Fibrillation and Cardiac Surgery: Current Medical and Invasive Approaches for the Treatment of Atrial Fibrillation

Atrial fibrillation (AF) is a cardiac dysrhythmia commonly seen in clinical practice especially after cardiac surgery. It is associated with increased morbidity and mortality for the patients. The pathogenesis of AF is not exactly understood yet, but there is growing data about the relationship between AF and inflammation. Cardiac surgery itself is a big source for inflammation. It causes major surgical trauma, ischemia/reperfusion injury, hypothermia, low arterial pressure, and the equipment of cardiopulmonary bypass makes a large foreign surface thus it activates inflammatory response. There is a large number of data about the treatment options of AF and there are also strategies, which are related to reduction of inflammatory activation during cardiopulmonary bypass. In order to review the relationship between cardiac surgery, inflammation, AF and treatment strategies in patients with AF, we conducted a search through Pubmed for articles in English using the keywords: "atrial fibrillation, cardiac surgery, inflammation, medical therapy, surgical therapy, ablation therapy" from January 2012 to present. We also searched separately for each alternative treatment modality on Pubmed. To identify further articles, we also looked into related citations in review articles and commentaries. We searched thoroughly the guidelines published by the European Society of Cardiology (2016), and the American Heart Association/ American College of Cardiology/ Heart Rhythm Surgery (2014). Many studies concluded that inflammation contributes in the occurrence of AF. Inflammatory markers, such as CRP, interleukins and complements have high sensitivity and specificity for prediction of AF whether the patient having cardiac surgery or not. Betablockers, diltiazem and amiodarone are the most commonly used drugs for rate control in AF following surgery. Although there are some new therapeutic approaches to reduce postoperative inflammatory activation, such as the use of vitamins, fatty acids, statins, or technical improvements to cardiopulmonary bypass unit like miniaturized bypass circuits, heparin coating of the circuits, leukocyte filters, or various surgical approaches like off-pump coronary bypass surgery, we still need more effective strategies to reduce both postoperative inflammation and postoperative AF risk after cardiac surgery. Today we use more advanced invasive and surgical treatment strategies for AF although we need far more advanced technics to reduce perioperative inflammatory activation, which actually causes AF.

Effects of age on systemic inflamatory response syndrome and results of coronary bypass surgery

Background

Coronary artery bypass (CAB) surgery triggerssystemic inflammatory response syndrome (SIRS) via severalmechanisms. Moreover, age is directly correlated with SIRS.We evaluated the effect of age on SIRS and postoperativeoutcome after CAB surgery.

Methods

We retrospectively reviewed the records of 229 patients who had undergone CAB surgery. The patients were divided into three groups according to age: group 1, < 40 years (n = 61); group 2, 40–75 years (n = 83); and group 3, > 75 years old (n = 85). Pre- and peri-operative data were assessed in all patients. SIRS was diagnosed according to the criteria established by Boehme.

Results

The average pre-operative EuroSCORE value in group 3 was higher than in the other groups and body surface areas were significantly lower in group 3 than in the other groups (p < 0.05). The postoperative SIRS rates were 68.9% in group 1, 84.3% in group 2 and 91.8% in group 3 (group 1 vs group 3; p < 0.05). Mortality rates were not significantly different between the groups (p > 0.05). The predictive factors for SIRS were age, EuroSCORE rate, on-pump CAB surgery and intra-aortic balloon pump use.

Conclusion

Age was an important risk factor for SIRS during the postoperative period after CAB.

Investigation of biochemical and histopathological effects of Mentha piperitaLabiatae and Mentha spicata Labiatae on liver tissue in rats

The plant Mentha piperita, or peppermint, is commonly used in the treatment of loss of appetite, common cold, bronchitis, sinusitis, fever, nausea and vomiting, and indigestion as a herbal agent. In this study, we aimed to investigate biochemical and histological effects of M. piperita Labiatae, growing in the Yenisar Bademli town of Isparta city, and Mentha spicata Labiatae, growing in the Anamas high plateau of the Yenisar Bademli town, on the rat liver tissue. Forty-eight male Wistar albino rats weighing 200-250 g were used for this study. Rats were divided into four groups of 12 animals: Group I received no herbal tea (control group); Group II received 20 g/L M. piperita tea; Group III received 20 g/L M. spicata tea; and Group IV received 40 g/L M. spicata tea. Herbal teas were prepared daily and provided at all times to the rats during 30 days as drinking water. Liver function tests, including aspartate aminotransferase (AST/GOT) and alanine aminotransferase (ALT/GPT) activities were measured. To evaluate liver antioxidant defences, superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), cata lase (CAT) and thiobarbituric acid reactive substance (TBARS) activities were determined in the homogenates of liver tissue. In addition, liver tissues were submitted for histopathologic examination. AST and ALT activities were increased in Group II, Group III and Group IV gradually when compared with the control group. The difference between Group II and the control group was not statistically significant (P > 0.016). Increases in AST and ALT activities of Group III and Group IV were statistically significant when compared with the control group. SOD, GSH-Px and CAT activities were increased in Group II when compared with the control group but the difference was not statistically significant (P > 0.016). However, SOD, GSH-Px activities and the TBARS level were significantly increased, and CAT activity was significantly decreased in Group III when compared with the control group. In Group IV, while SOD, GSH-Px and CAT activities were decreased, the TBARS level was increased as compared with the control group (P < 0.0016). Histopathological evaluation of experimental groups revealed a mild to severe degree of hepatic damage when compared to the control group. In Group II, there was only minimal hepatocytes degeneration. In Groups III and IV, there were granular or ballooning hepatocyte degeneration and necrosis, sinusoidal and central vein dilatation. It was concluded that lipid peroxidation and hepatic damage occurs after M. piperita and M. spicata administration in rat liver and the damage seems to be dose dependent.

Does calcium dobesilate protect against intestinal ischemia-reperfusion injury induced in rats?

OBJECTIVE

In this study, we investigated whether the administration of calcium dobesilate (CD) affects oxidative stress markers and histopathological outcomes in a rat model of intestinal ischemia-reperfusion (IR) injury.

MATERIALS AND METHODS

This study was conducted with 30 male Wistar rats. The rats were randomly assigned to three groups as follows: a sham group (n = 10), an IR group (n = 10), and an IR + CD group (n = 10). In the sham group, superior mesenteric artery (SMA) dissection alone was performed during laparotomy. In the IR group, the procedure included SMA occlusion for 60 min, followed by reperfusion for 60 min. In the IR + CD group, CD (100 mg/kg/day) was additionally given for two days before laparotomy by intragastric lavage. In all the rats, 2 ml of blood were drawn, and an ileal segment (approximately 2 cm in size) was removed to evaluate oxidative stress markers. The ileal segment removed was divided into two pieces, and one piece was reserved for histopathological evaluation.

RESULTS

Compared to the other groups, both serum and tissue oxidative stress indices were lower in the IR + CD group. The decrease was due to CD increasing the total antioxidant capacity. Moreover, the histological analysis showed that CD reduced tissue injury.

CONCLUSIONS

CD may exert a protective effect against intestinal IR injury by increasing antioxidant capacity.

Surgical management of axillosubclavian vascular injuries

Objective:

Complex surgical exposures to upper extremity injuries required for conventional surgery correlate with a high morbidity and mortality. We present our results with conventional surgery following injuries of the subclavian and axillary vessels.

Methods:

Between November 2007 and March 2012, 29 cases with subclavian-axillary vascular injury were operated. Diagnostic and treatment methods, associated organ injury, morbidity and mortality rates in these cases were respectively reviewed.

Results:

The causes of injuries were stab wounds in 11 cases (37.9%), gunshot wounds in 9 cases (31%), iatrogenic injuries in 5 cases (17.2%) and blunt trauma 4 cases (13.7%). Eight patients (27.5%) had isolated arterial injury while 21 patients (72.4%) had coexisting organ injury (vein, bone, soft tissue, nerve). Primary repair and usage of saphenous vein were the most common surgical methods. One patient died due to myocardial infarction. (Mortality 3.4%)

Conclusions:

Vascular injuries of axillosubclavian are frequently associated with neurogenic, osseous and soft tissue injuries and should have early intervention. Conventional surgery remains the choice of treatment in patients with poor status and urgency.

An alternative method of transperitoneal graft introduction in aortobifemoral bypass surgery

INTRODUCTION

Intestinal injury and bleeding, which usually occurs while taking the graft through the transperitoneal tunnel, is one of the most important complications of aortobifemoral bypass surgery. In this study, case reports were examined where, for some reason, the tunneller instrument could not be used to create the transperitoneal tunnel and the tunnelling forceps was used. In some of these cases, the grafts were taken through conventionally and in others an alternative method was used.

METHODS

Between 2002 and 2013, the records of 81 patients treated surgically by aortobifemoral bypass for peripheral arterial disease, were investigated retrospectively. In the conventional method, after creating a tunnel with tunnelling forceps, the forceps was re-introduced into the tunnel and the graft was clasped and brought through the tunnel. In the alternative method, a nylon tape was left as a guide in the tunnel while creating the tunnel, and the forceps was not introduced again. The graft was taken through the tunnel with the help of the nylon tape. Patients treated with the conventional method were included in group 1 (n = 49) and patients in which the graft was guided with nylon tape were included in group 2 (n = 32). The groups were compared peri-operatively.

RESULTS

There were no significant differences between the groups in terms of co-morbidity factors. Extubation time, intensive care length of stay, revision for bleeding, other postoperative complications, and infection and late-term infection rates were similar in the two groups (p > 0.05). Hospital length of stay and blood usage were significantly higher in group 1 (p < 0.05). Drainage amounts were higher in group 1 but not statistically significant.

CONCLUSION

Using nylon tape to introduce the graft into the femoral area during aortobifemoral bypass operations was found to be more effective than using the tunnelling forceps.

Emergency surgical approach to device emboli due to migration of the atrial septal defect occluder

INTRODUCTION

Atrial septal defect (ASD) transcatheter occlusion techniques are now established as the preferred method and have become an alternative to surgery under extracorporeal circulation. In this study, we aimed to present our emergency surgical approach to cases of device embolization due to migration of the atrial septal defect occluder.

MATERIAL AND METHODS

Between June 2009 and June 2011, 6 patients underwent emergency operations due to device emboli secondary to migration of the transcatheter atrial septal defect occluder during the early period. Mean age was 25.5 years (15-45) and 3 of the patients were female (50%). The diagnosis was made via transthoracic echocardiography (TTE) preoperatively.

RESULTS

All of these 6 patients underwent emergency operations. Mean postoperative intensive care unit (ICU) stay was 2.2 days and mean hospital stay was 6 days. No early or late postoperative mortality was seen. Mean postoperative follow-up time was 19.3 months (range: 5-28 months). Early- and late-period TTE examinations showed no residual interatrial shunting. One patient developed a right atrial thrombus in the postoperative 22(nd) month as a complication of long-term follow-up. He was treated with anticoagulant therapy for 6 months with complete resolution at the TTE.

CONCLUSIONS

Transcatheter occlusion of secundum type ASD provides prominent clinical improvement, as well as a regression in dimensions of cardiac chambers. Nevertheless, this technique has drawbacks such as distal migration and residual shunts. Consequently, we think that unfavorable anatomy and device diameter are major issues in device migration. Oversizing also increases the migration risk.