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Objectives: Obesity is a risk factor for morbidity after isolated coronary artery bypass grafting. This study aimed to analyze the sole effect of body mass index (BMI) on early morbidity and mortality in patients after isolated coronary artery bypass grafting., Design: This study was retrospective and used an electronic database of anesthesia information management., Setting: A single community hospital., Participants: The data of 803 consecutive patients after isolated on-pump coronary artery bypass grafting were analyzed retrospectively; off-pump cases were excluded., Intervention: According to measured BMI, patients were divided into 5 groups: underweight (BMI <20 kg/m(2)), normal weight (BMI 20.0-24.9 kg/m(2)), overweight (BMI 25.0-29.9 kg/m(2)), obese (BMI 30.0-34.9 kg/m(2)), and morbidly obese (BMI >34.9 kg/m(2)). Early postoperative morbidity and mortality were evaluated using logistic regression analysis., Measurements and Main Results: Early cumulative postoperative mortality was 3.9% (32 of 803 patients). Mortality was recorded in 3 underweight (n = 15, 20%, odds ratio [OR] 6.54, p = 0.001), 9 normal-weight (n = 159, 5.7%, OR 1.62, p = 0.228), 12 overweight (n = 371, 3.2%, OR 0.68, p = 0.314), 6 obese (n = 199, 3.0%, OR 0.69, p = 0.421), and 2 morbidly obese (n = 59, 3.4%, OR 0.83, p = 0.808) patients. Prolonged intensive care unit stay (p < 0.001), prolonged hospital stay (p < 0.001), and mortality (p = 0.01) were significantly more common in patients in the underweight group than in the other groups. Univariate and multivariate logistic regression analyses showed that underweight, hypertension, and chronic renal failure were independent risk factors for mortality., Conclusions: Underweight patients with a BMI <20 kg/m(2) are at increased risk of postoperative complications and mortality compared with normal-weight or overweight subjects., (Copyright © 2012 Elsevier Inc. All rights reserved.)

A total of 25 patients undergoing coronary artery bypass grafting (CABG) were included in the study. Patients received statin (20 mg daily) postoperatively for 2 weeks. All analyses were performed at 2 different time points: preoperatively (group 1) and 2 weeks after operation (group 2). Interleukin (IL)-6, IL-8, plasminogen activator inhibitor 1 (PAI-1), tumor necrosis factor α (TNF-α), tissue plasminogen activator (t-PA) levels, and tissue factor pathway inhibitor (TFPI) were evaluated. Statin treatment caused a significant reduction in the plasma level of PAI-1 (preop: 15.04 ± 0.13 ng/mL vs postop: 13.89 ± 2.14 ng/mL; P < .05) and increased t-PA levels (preop: 109.74 ± 0.13 vs postop: 231.40 ± 1.22 ng/mL; P < .001). Plasma TNF-α and IL-6 levels did not change with treatment. Statin treatment caused a significant reduction in plasma IL-8 level (279.70 ± 3.42 ng/mL vs postop: 207.18 ± 3.63 ng/mL, P < .05), and TFPI (4.87 ± 2.05 ng/mL vs postop: 6.27 ± 1.25 ng/mL; P < .05). The results demonstrate that atorvastatin attenuates systemic inflammatory reaction after cardiac surgery.

Objective: We aimed to compare the effects of 2 different antiplatelet agents on platelet activity in patients receiv- ing atorvastatin after coronary artery bypass grafting (CABG)., Methods: We prospectively randomized 50 patients undergoing CABG into 2 groups; group 1 started to receive atorvastatin (10 mg) plus clopidogrel (75 mg; C + A, n = 25) and group 2 atorvastatin (10 mg) and acetylsalicylic acid (ASA; 300 mg, ASA + A, n = 25) daily on postoperative day 1 and continued for 6 months after operation. Adenosine diphosphate (ADP)-induced platelet aggregation and the expressions of glycoprotein (Gp) IIb, GpIIIa, P-selectin, and fibrinogen (Fg) and low-density lipoprotein (LDL) binding to platelets were assessed preoperatively and at postoperative days 7, 90, and 180., Results: The mean age of the patients was 59.6 +/- 7.6 years, and 82% of the patients were males. The combination of C + A markedly inhibited ADP-induced platelet aggregation compared with ASA + A at postoperative days 90 and 180 (52% +/- 6.0% vs 56% +/- 7.25% and 19.6% +/- 3.2% vs 37% +/- 4.1%, P = .039 and P = .0001, respectively). The therapy of C + A significantly suppressed the expressions of GpIIIa at postoperative days 7, 90, and 180 (P = .0001, P = .0001, and P = .0001, respectively) and P-selectin at postoperative days 90 and 180 (P = .035 and P = .002, respectively) when compared to ASA + A. The expression of GpIIb was also significantly depressed at postoperative day 180 in group 1 when compared to group 2 (P = .0001). Low-density lipoprotein binding was significantly increased at day 180 postoperatively in both the groups (basal: 42.9% +/- 5.6% vs 45.3% +/- 4.4% and day 180: 60.3% +/- 4.6% vs 61.8% +/- 5.7%, P = .0001)., Conclusions: Our results demonstrate that the combination of C + A is more effective than that of ASA + A in inhibiting ADP-mediated platelet aggregation and expression of major platelet receptors after CABG.

Objective: Acute kidney injury (AKI) is a devastating complication following cardiac surgery and the ideal management is controversial. This prospective, randomized, open-label and double-blinded study analyzed the renoprotective effects of furosemide infusion and intermittent bolus therapy administered with dopamine infusion in cardiac surgical patients., Methods: Between August 1, 2007 and July 31, 2008, 100 adult patients undergoing elective coronary artery bypass surgery (CABG) surgery with normal renal function (creatinine <1.4 mg/dl) were enrolled in the study. The patients were randomized for the comparison of intermittent (Group 1, n=50, 1mg-3mg/kg) and continuous infusion of furosemide (Group 2, n=50, 10mg/ml). Continuous variables were expressed as mean+/- SD and compared by unpaired Student's t test or ANOVA for repeated measures. Statistical significance was assumed if p value was <0.05., Results: Renal replacement therapy (RRT) was used in 5% of patients (all in group 1, p=0.028). The 30-day mortality was 5%. Only 2 patients became hemodialysis dependent in group 1. Group 2 patients showed a continuous and higher urine output postoperatively than group 1 (p<0.001). Both groups had significant increase in peak postoperative serum creatinine values (p<0.001), however peak postoperative creatinine-clearance was significantly lower in group 1 (p<0.001)., Conclusion: Acute kidney injury necessitating RRT makes a small percentage of patients undergoing cardiac surgery and if RRT is not required the survival is excellent. Continuous infusion of furosemide seems to be effective in promoting diuresis and decreasing the need for RRT. However further multicenter studies with different doses of furosemide are required to confirm these results.

Objective: Bleeding and allogeneic transfusion remain constant problems in cardiac surgical procedures. In this study, we aimed to test the role of a routine thromboelastography (TEG)-based algorithm on bleeding and transfusions in patients undergoing elective coronary artery bypass grafting (CABG)., Methods: Patients (n = 224) undergoing elective CABG with cardiopulmonary bypass were prospectively randomized into two groups according to transfusion strategy: in group 1 (clinician-directed transfusion, n = 110) need for blood transfusion was based on clinician's discretion and standard coagulation tests and in group 2 (TEG algorithm group, n = 114) kaolin-activated (k) TEG-based algorithm-guided perioperative transfusion management. Transfusion, blood loss, and outcome data were recorded., Results: There were no differences in consumption of packed cell units, blood loss, re-exploration for bleeding, and early clinical outcome between the groups. Patients in the TEG group had significantly lower median units of fresh frozen plasma and platelets compared with the other group (p = 0.001). The median number of total allogeneic units transfused (packed cells and blood products) was significantly reduced in the TEG group compared with the other group (median 2, range 1-3 units vs. median 3, range 2-4 units, respectively, p = 0.001). The need for tranexamic acid was significantly diminished in the TEG group compared with the other group (10.3% vs. 19%, respectively, p = 0.007)., Conclusion: Our results show that routine use of a kTEG-guided algorithm reduces the consumption of blood products in patients undergoing elective CABG. Adopting such an algorithm into routine management of these patients may help to improve clinical outcome and reduce the potential risks of transfusion-related complications and total costs after CABG.

Objectives: We evaluated the effect of transmyocardial laser revascularization (TMR) on anginal symptoms and clinical results in patients in whom coronary artery bypass grafting (CABG) surgery was not sufficient to provide complete revascularization., Study Design: This retrospective study included 45 patients who underwent CABG surgery with incomplete revascularization between 2003 and 2006. Of these, 35 patients (mean age 61.7 years) had CABG alone, while 10 patients (mean age 62 years) underwent TMR at the same session as an adjunct to CABG. All the patients were assessed by transthoracic echocardiography and myocardial perfusion scintigraphy at three months and after a mean follow-up period of 22.3+/-6.1 months. Anginal symptoms were assessed using the CCS (Canadian Cardiovascular Society) classification system., Results: Preoperative variables were similar in both groups. All the patients were symptomatic preoperatively with mean CCS scores of 2.6+/-0.5 and 2.3+/-0.8 in the TMR and CABG-alone groups, respectively. The duration of cardiopulmonary bypass (CPB) was significantly longer in the TMR group (p=0.022). During weaning from CPB, the need for inotropic support was significantly less in the TMR group (10% vs. 48.6%; p=0.034). While there was no early mortality, late mortality occurred in three patients (1 in TMR, 2 in CABG-alone groups; p=0.329). At three months, 50% (n=5) of the TMR patients were asymptomatic, compared to 14.3% (n=5) in the CABG-alone group (p=0.016). Patients in the TMR group had significantly lower CCS angina scores at three months (1.2+/-0.6 vs. 2.2+/-0.7; p=0.001) and at the end of the follow-up (1+/-0.6 vs. 2+/-0.7; p=0.001). There were no significant differences between the two groups with regard to the findings of myocardial perfusion scintigraphy and echocardiography., Conclusion: Patients with incomplete surgical revascularization benefit from TMR in terms of decreased need for inotropic support during weaning from CPB and short- and mid-term relief of angina symptoms.

Thromboelastography is an alternative method to conventional coagulation tests for the general evaluation of hemostatic system. Cardiac surgery with cardiopulmonary bypass is accomplished by complex alterations of hemostasis, including acquired dysfunction of platelets, consumption coagulopathy and increased fibrinolysis. Despite major advances in blood conservation methods and perioperative care of the patients, transfusion rates in cardiac surgery remain high. Thromboelastography has an ability to assess almost all components of haemostatic system globally. Currently, thromboelastography is used with standard coagulation tests to decrease the microvascular bleeding and homologous blood transfusion in cardiac surgery with cardiopulmonary bypass. In this review, we aimed to discuss thromboelastography technology and its usage in cardiac surgery.

Background: Ischemia-reperfusion injury and inflammation in cardiac surgical patients involves complex humoral and cellular interactions. We investigated the effect of genetic polymorphism of manganase superoxide dismutase (MnSOD) a natural antioxidant, on cytokine release and manganesuperoxide dismutase in patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB)., Patients and Methods: Forty-two patients undergoing elective CABG with CPB were included in the study. MnSOD polymorphism was performed by polymerase chain reaction (PCR). Levels of interleukin-6 and mangane superoxide dismutase (MnSOD) were measured by enzyme linked immunoabsorbent assay (ELISA)., Results: Baseline IL-6 did not differ between patients with different MnSOD genotypes. Postoperatively IL-6 levels were significantly higher in all patients but more significantly in V(VV+AV) carriers (p=0.003). The wild-type AA genotype had the highest preoperative (p<0.05) and postoperative IL-6 level. The MnSOD VV genotype was associated with significantly lower preoperative MnSOD levels compared to the AA carriers (p<0.05)., Conclusion: These data demonstrate that MnSOD Ala16Val polymorphism influences IL-6 production and baseline MnSOD activity, suggesting that preoperative MnSOD concentration plays a role in cytokine release.

Objective: Current data suggest that individual genetic predisposition may influence the magnitude of cytokine response and the degree of organ dysfunction after cardiopulmonary bypass. Lipoprotein lipase S447X polymorphism has been shown to be protective against atherosclerosis. The aim of the study was to investigate the effect of lipoprotein lipase S447X polymorphism on cytokine release and early outcome after cardiopulmonary bypass., Methods: Forty patients who underwent coronary artery bypass grafting with cardiopulmonary bypass were included. Genotyping for lipoprotein lipase S447X polymorphism was performed by polymerase chain reaction. Levels of interleukins 6 and 8 were measured before induction and 6, 24, and 72 hours after operation by enzyme-linked immunosorbent assay. Clinical data were collected prospectively. Daily assessment of organ dysfunction was done according to the cardiac surgery scoring (CASUS) system., Results: The allele frequency of lipoprotein lipase S447X stop codon was 17.5%. S447X carriers revealed significantly lower interleukin 8 levels at the sixth and 24th postoperative hours than the noncarrier group (P = .005 and P = .041, respectively). Patients in the S447X carrier group had significantly shorter ventilation times than the noncarrier group (P = .048). Also, the S447X carrier group revealed significantly lower postoperative 6-hour lactate levels, operative day, and postoperative day 1 organ dysfunction scores than the other group (P = .001, .005 and .002, respectively)., Conclusion: Lipoprotein lipase S447X stop codon mutation is associated with lower levels of interleukin 8 after coronary artery bypass grafting. Identification of high-risk patients for cardiopulmonary bypass-related systemic inflammation by detecting lipoprotein lipase S447X stop codon polymorphism may improve early postoperative outcome, especially in patients with limited organ reserves.

The concomitant presence of myeloproliferative disorders and the need for coronary artery bypass surgery is a surgical dilemma. Thrombosis and hemorrhage can cause difficult problems and might require different approaches during and after surgery. We report a patient who had idiopathic myelofibrosis and underwent a successful coronary artery bypass surgery.

Background: Acute kidney injury is one of the most serious complications after cardiac surgery. Genetic polymorphisms are reported to be associated with postoperative renal impairment. The aim of this study was to investigate the relationship between selected gene polymorphisms and acute kidney injury after cardiac surgery., Methods: Two hundred forty-eight elective coronary artery bypass grafting procedure patients were enrolled in the study. Angiotensin-converting enzyme (ACE) II, ID, and DD, apolipoprotein E (APO E), and angiotensin II type 1 receptor (AGTR1) A1166C genotypes were detected by polymerase chain reaction. Plasma levels of ACE were analyzed by enzyme-linked immunosorbent assay. Acute kidney injury after cardiac surgery was graded according to the RIFLE (risk, injury, failure, loss, and end-stage kidney disease) classification., Results: In our study, 21.8% of patients had acute renal impairment after cardiac surgery. Among the 54 patients with acute kidney injury, ACE D allele frequency was 0.620. The plasma levels of ACE were significantly higher in the D allele carriers (P = .018). Three of the 54 patients with acute kidney injury were APO E epsilon 4 allele carriers (P = .002). AGTR1 C allele carriers constituted 46% of all patients with postoperative acute kidney injury. There was no statistically significant difference between A allele homozygotes and C allele carriers with respect to postoperative renal dysfunction (P > .05)., Conclusions: The present findings support the hypothesis that ACE I/D and APO E gene polymorphisms may play a role in the development of acute kidney injury after cardiac surgery. However, AGTR1 does not have a unique association with postoperative renal impairment.

Objective: The optimal treatment of patients with co-existing occlusive coronary and carotid arterial disease is controversial. This study reports our experience with simultaneous carotid endarterectomy and coronary bypass in conjunction with cardiopulmonary bypass with mild hypothermia., Methods and Results: From March 2001 to June 2004, 72 patients underwent simultaneous coronary bypass and carotid endarterectomy. Their mean age was 68.9 years and there were 56 men and 16 women. The indication for carotid endarterectomy was a lumen diameter reduction of more than 75% and/or the presence of ulcerated/unstable plaque. Carotid endarterectomy was done during cardiopulmonary bypass under mild hypothermia, haemodilution, systemic heparinization and controlled haemodynamics under pulsatile perfusion for additional cerebral protection. The mean cardiopulmonary bypass time was 64.7 minutes and aortic cross-clamp time 32.4 minutes, and the mean number of grafts per patient was 2.7. Four patients had perioperative neurological complications (5.5%) and two had permanent deficits (2.7%). The procedure-related mortality was 3 (4.1%)., Conclusions: We suggest that combining coronary revascularization and carotid endarterectomy and performing both under cardiopulmonary bypass is safe, offering acceptable morbidity and mortality rates.

Objective: The role of coronary artery bypass grafting (CABG) in patients with severe left ventricular dysfunction was evaluated., Methods: Two hundred and twelve patients (152 men, 60 women; age 35 to 82, mean 55) with ejection fraction (EF) of less than 30% underwent CABG between January 1996 and February 2001 by a single surgeon (SA). They compromised of 12% of 1759 patients operated on in this period. EF ranged from 17% to 30% (mean 25%). Preoperatively 68% had congestive heart failure and 72% had severe angina (CCS 3 or 4). A left main lesion was found in 26% of the cases. The mean number of grafts was 3.18 per patient. The left internal mammary artery (LIMA) was used on 107 patients (50.4%). Preoperative intraaortic balloon pump (IABP) was used on 32 patients (15%). Endarterectomy was performed on 53 patients (25%). The patients were followed for up to 58 months (mean 28.7)., Results: Twelve patients died in hospital (5.6%). Survival was 94%, 87%, 80% and 73% at 1, 2, 3 and 4 years respectively. Among the preoperative variables survival was negatively affected by chronic renal failure, older age, congestive heart failure, elevated pulmonary artery pressure and recent myocardial infarction, by means of multivariate analysis. Preoperative IABP support improved the operative mortality significantly (P=0.002). Use of LIMA did not have any influence on survival., Conclusion: CABG on patients with poor left ventricular function: (1). Can be performed with an acceptable mortality. (2). Mid term results are encouraging. (3). Preoperative IABP support improves the chance of survival.