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Amaç: Koroner arter cerrahisinde greft açık kalma süresi endotel fonksiyonuna bağlıdır. Nitrik Oksitin (NO) endotel fonksiyonuna yararlı etkisi bilinmektedir. Greftlerdeki Nitrik Oksit düzeyi ve Losartan’ın Nitrik Oksit üzerine etkisi invitro olarak araştırılmıştır. Yöntem: Çalışma 13 hasta da 78 örnek ile yapıldı. İnternaltorasik arter, radial arter ve safenvengreft örnekleri “Kontrol Grubu” ve “Losartan Grubu” olmak üzere ikiye ayrıldı. Losartan grubu örnekleri 1 x 10-5molar Losantanlı Troyde’s solüsyonu çözeltisi içinde inkübe edildi. Nitrik Oksit, Griess yöntemi kullanılarak ölçüldü. İstatistiksel değerlendirme. Kruskal Wallis Oneway ANOVA, İndependentsample T ile Tukey ve Bonferroni testleri kullanılarak yapıldı. Bulgular: Kontrol grubu bazal Nitrik Oksit değeri, internaltorasik arter greftinde anlamlı olarak yüksek bulunmuştur (p

Summary Background Obtaining vascular access suitable for long-term use in hemodialysis patients is of utmost importance. In these patients, autogenous methods are generally used for access. There are various techniques for obtaining autogenous access in hemodialysis patients. Material/Methods Our objective was to evaluate the outcomes of the “diamond-shaped anastomosis” technique used as a surgical technique during the creation of arteriovenous fistulas in patients with chronic renal failure. We randomly selected and retrospectively examined 67 patients on whom the “diamond-shaped anastomosis” technique had been performed. Results We found an 89% patency rate in the 67 randomly selected patients on whom we applied this technique in the early stage (first 6 months). Conclusions Maintaining fistula patency in the early postoperative period is important in fistula functioning. The diamond-shaped anastomosis is a simple technique with proven efficiency. This method can be applied in all situations and contributes to postoperative early stage latency.

This prospective randomized study investigated the effects of two different cardioplegia techniques on myocardial heat shock protein 70 (HSP70) mRNA levels. Patients undergoing elective coronary artery bypass grafting with cardiopulmonary bypass (CPB) were divided into two equal groups. All patients received the same anaesthesia. Myocardial preservation was achieved by delivering intermittent antegrade isothermic blood cardioplegia in one group and antegrade plus continuous retrograde isothermic blood cardioplegia in the other. Biopsies for measurement of HSP70 mRNA levels were taken from the right atria before surgical manipulation of the heart, and later from the same place following CPB. HSP70 mRNA levels were evaluated using quantitative real-time reverse transcription—polymerase chain reaction. Crossing-point values for HSP70 and β-actin were used to evaluate up-regulation. There was a significant increase in HSP70 mRNA levels in response to CPB in both groups, but no significant between-group difference in HSP70 up-regulation. Further investigation is required to evaluate the correlation between the level of HSP induction and the degree of myocardial protection in more heterogeneous groups of patients.

Many thoracic aortic aneurysms are discovered incidentally, and most develop without symptoms. Symptoms are usually due to sudden expansion of the aneurysm, which can cause a vague pain in the back, or sometimes a sharp pain that may denote the presence of impending rupture. Other symptoms are related to pressure on adjacent structures, such as pressure on the bronchus that can cause respiratory distress, or pressure on the laryngeal nerve causing vocal hoarseness. Pressure on the esophagus can cause difficulty in swallowing. Currently, open surgery and thoracic endovascular aneurysm repair (TEVAR) are the choices of treatment for descending thoracic aneurysms (DTA). The decision to intervene on a DTA depends on its size, location, rate of growth and symptoms, and the overall medical condition of the patient. The indications for TEVAR should not differ from those for open surgery and typically include aneurysms larger than 6 cm in diameter. Saccular and symptomatic aneurysms are often repaired at a smaller size. It is also suggested that aneurysms with a growth rate more than 1 cm per year, or 0.5 cm in 6 months should be considered for early repair.Despite the close proximity of the aorta and left main bronchus, atelectasis caused by thoracic aortic aneurysms is rare. We review the case report of a patient with concomitant persistent left pulmonary atelectasis causing acute respiratory distress due to complete compression of the left main bronchus after TEVAR of a descending thoracic aortic aneurysm.

Adhesions due to the reactions caused by the grafts used in primary vascular operations can lead to various problems when a secondary operation is necessary. These problems include bleeding, injuries to neighboring organs, and complications occurring due to a prolonged operation. We investigated the effects of sirolimus, which has antiproliferative features, on vascular adhesions.The abdominal aorta of rats was explored and abrasions applied. Following the fixation of a polytetrafluoroethylene (PTFE) graft on the abdominal aorta, sirolimus (rapamycin) is applied (in powdered form) onto the grafts of the study group. Eight weeks later a laparotomy was repeated and any adhesions were evaluated.In the study group the adhesions were determined to be fewer in number and milder in severity. Severe cases of adhesion were determined in the control group.Therefore, sirolimus applied around the prosthesis in vascular operations was determined to be effective at preventing possible adhesions.

This study investigated the protective effects of carvedilol, a potent antioxidant, in a rat model of tourniquet-induced ischaemia-reperfusion injury of the hind limb. Thirty rats were divided equally into three groups: the control group (group 1) was only anaesthetized, without creating an ischaemia-reperfusion injury; group 2 was submitted to ischaemia (4 h), followed by a 2-h reperfusion period; and group 3 was pre-treated with carvedilol (2 mg/kg per day) for 10 days prior to ischaemia-reperfusion. Ischaemia-reperfusion produced a significant decrease in superoxide dismutase and glutathione peroxidase activities in the liver, lungs, muscle and serum compared with control treatment, and pre-treatment with carvedilol prevented these changes. Ischaemia-reperfusion caused a significant increase in malondialdehyde and nitric oxide (NO) levels in liver, lungs, muscle (except NO) and serum compared with control treatment, and carvedilol prevented these changes. In conclusion, it might be inferred that carvedilol could be used safely to prevent oxidative injury during reperfusion following ischaemia in humans.

Between March 1996 and September 1997, videothoracoscopy was performed in 50 of 140 patients who underwent minimally invasive coronary artery bypass grafting. Mean age was 45.3 ± 6.8 years. The left internal mammary artery was harvested by thoracoscopy alone in 21 patients and by both thoracoscopy and direct vision in 29. Coronary artery bypass was then performed through a left anterior minithoracotomy. In 48 patients, the internal mammary artery was grafted directly to the left anterior descending artery; a small saphenous vein graft was interposed in the other 2 patients. The diagonal branch was bypassed with saphenous vein in 2 patients, the first obtuse marginal in 1, the right posterior descending branch in 1, and the right ventricular branch of the right coronary artery in 1. Concomitant carotid endarterectomy was performed in 1 patient. There was no mortality. Two patients had perioperative myocardial infarction. It was concluded that videothoracoscopy can help to achieve complete mobilization of the left internal mammary artery for minimally invasive coronary artery bypass grafting. These techniques can be regarded as safe and effective, giving excellent results and a shortened hospital stay with the advantage of avoiding some morbidity due to costal cartilage resection.

Objective: Recently, closed mitral commissurotomy (CMC) has been reexplored due to the concepts of less invasive valvular surgery. The feasibility of closed mitral commissurotomy via port access or limited thoracotomy by aid transesophageal echocardiography (TEE) was investigated in this clinical study. Methods: Between August 1996 and April 1998, 42 patients (32 women, ten men with a mean age of 36.2 ∠ 7.8 years) underwent less invasive CMC at the Kosuyolu Heart and Research Hospital. CMC procedure were done through a limited (12‐16 cm) thoracotomy incision in 23 patients, a very limited or mini thoracotomy incision (7‐8 cm) in 11 patients and port access by aid TEE in eight patients. Preoperative mean mitral valve area was calculated as 1.19 ∠ 0.13 cm 2 and mean mitral valve gradient was measured as 14.8 ∠ 3.2 mmHg. TEE provided information about the mitral valve anatomy and functions during the procedure in all patients. Results: Commissurotomy was successfully performed in all patients. In eight patients, a Tubbs dilator was inserted via port access at the 6th intercostal space from a 3-cm incision. Incision by guidance of TEE and CMC could be performed without thoracotomy in five patients. In three patients of the port access group, a very limited thoracotomy was required to perform CMC by digital guidance. Postoperative mean MVA was 2.37 ∠ 0.29 cm 2 , minimal mitral gradient was 5.3 ∠ 1.7 mmHg. In eleven patients, minimal mitral regurgitation was observed. The operations and postoperative period were free of complications in all patients. Following an average 12 ∠ 2.8 h intensive care unit period, all patients were discharged after an average of 3.4 ∠ 0.8 days of hospitalization. Conclusion: Limited thoracotomy has less detrimental structural effects in patients. Port access by aid TEE approach to CMC may offer less invasiveness, lower cost effectiveness and be an alternative to percutaneous balloon mitral valvotomy. © 1998 Elsevier Science B.V. All rights reserved

Pericardial fluid (PF) is often considered to be reflection of the serum by which information regarding the physiological status of the heart can be obtained. Some local and systemic disorders may perturb the balance between synthesis and discharge of PF and may cause its aberrant accumulation in the pericardial cavity as pericardial effusion (PE). PE may then lead to an increased intrapericardial pressure from which the heart function is undesirably affected. For some cases, the causes for the perturbance of fluid balance are well understood, but in some other cases, they are not apparent. It may, thus, be helpful to understand the molecular mechanisms behind this troublesome condition to elucidate a clinical approach for therapeutic uses. In this study, protein profiles of PEs from idiopathic pericarditis patients were analyzed. Control samples from patients undergoing elective cardiac surgery (ECS) were included for comparison. In addition to high abundant serum-originated proteins that may not hold significance for understanding the molecular mechanisms behind this disease, omentin-1 was identified and its level was higher for more than two-fold in PE of IP patients. Increased levels of omentin-1 in PE may open a way for understanding the molecular mechanisms behind idiopathic pericarditis (IP).

Centrifugal pumps are nonocclusive pumps that offer centrifugal blood pumping known as the constrained force vortex principle. Of 2405 open heart procedures, 370 (15.4%) were performed with a centrif ugal pump (CP). In the rest of the cases extracorporeal circulation (ECC) was established with conventional roller pump (RP). The operations performed with a CP were: 34 reoperations, 11 ascending aortic aneurysms + coronary artery bypass graft (CABG), 47 multivalve replacements, 125 CABG + left ventricu lar aneurysmectomies, and 153 CABGs alone. This prospective study consisted of two groups, each group including 50 patients undergoing CABG surgery. In group I ECC was established with a CP and in group II with a conventional RR The two selected groups of patients were considered to be similar in terms of clinical, hemodynamic, and angio graphic data. Hemodynamic study concerned flow rate, systemic vascular re sistance (SVR), and urinary output. No difference was found between the CP and RP hemodynamically. Nevertheless, the alteration of the flow rate in re sponse to variation of SVR is accepted as an advantage. As for hemolytic effect during ECC of CP compared with RP: Plasma free hemoglobin, hemotocrit, platelet count, platelet factor 4, and fibrinogen levels, were investigated. These parameters revealed that there was significant hemoly sis and trauma to the blood components in the RP group when compared with the CR (p < 0.05, p < 0.01). There was no significant difference in psychoneurologic complications, but behavioral and sensory disorders were encountered sevenfold more in the RP group. This might be due to spoliation of the tubing set or to microair embo lism. Compared with the conventional RP the CP proved to have no hemodynamic advantage. The effects on blood components showed significant trauma to the RP group. Postoperative drainage verified this observation (p < 0.05). In this study the CP appears to be superior to the RP especially in compli cated and prolonged ECC.

The aim of this study to investigate prognostic efficacy of high sensitivity C-reactive protein (hs-CRP) in patients with acute coronary syndrome (ACS) and to identify the most valuable cut-off value of hs-CRP for determining long term prognosis.A total of 240 ACS patients presenting within 6 h after the onset of chest pain were included to the study. Admission levels of hs-CRP were analyzed. Patients were followed for 1 year. Primary end-point of the study was new coronary event (NCE), defined as the combination of cardiac death, nonfatal myocardial infarction and recurrent rest angina. Risk factors for NCE were determined by logistic regression analysis. ROC-curve analysis was used to identify cut-off values of the risk factors. The prognostic efficacy of the cut-off value of hs-CRP was compared to other values determined from other studies. Kaplan Meier and log rank tests were used in survival analyses. Factors determining event-free survival were investigated by Cox regression analysis.During the follow-up period, 65 NCEs occurred. In multivariate analysis, hs-CRP was strongly associated with the occurrence of NCE (OR=4.79, 95% CI=2.10-10.44, p0.001). Cut-off value of hs-CRP for NCE was 1.1 mg/dl (AUC=0.68, 95% CI=0.62-0.74, p0.001). Compared to other values of different studies, hs-CRP1.1 mg/dl had the optimal positive and negative predictive values. In the Cox regression analysis, hs-CRP was emerged as the most important parameter for determining event-free survival (RR=3.44, 95% CI=1.91-6.21, p0.001).Admission levels of hs-CRP were emerged as the most important parameter for prognosis and the cut-off value of hs-CRP for predicting NCE was found as 1.1 mg/dl in this cohort of the study population. Further studies are required to confirm the most risky cut off value of hs-CRP for predicting long term prognosis among ACS patients and in general population.

Of 632 valvular heart disease patients 187 were operated on because of multivalvular rheumatic lesions. The operative mortality was 10.1% and late mortality 4.9%. Left ventricular dysfunction was the common cause in the early operative period. Prosthetic valve endocarditis and thromboembolism were the other common causes of mortality, 5.9% and 6.4% respectively. NYHA Class III-IV, pulmonary hypertension, ejection fraction less than 40%, aortic stenosis and elevated left ventricular end diastolic pressure were significant predictors of poor-prognosis. Tricuspid regurgitation due to right heart decompensation is also another grave sign. The type of the prosthetic valve or additional annuloplasties to double valve replacement did not influence the outcome. Optimal timing of the operation is essential. Urgent operations should always be avoided if possible. Earlier surgical intervention, improved perioperative myocardial preservation, and alternate support methods, and improved surgical techniques may lower the operative mortality and morbidity.

Various priming solutions are currently used to prime heart-lung machines for cardiac operations. Hemodilution has resulted in considerable conservation of blood, as well as diminution of plasma and corpuscle damage, by decreasing the concentration of these elements in blood during extracorporeal circulation. Controversy has existed regarding the relative efficacy of various hemodilution solutions. In this prospective study two groups of similar open-heart patients, the first receiving hydroxyethyl starch (HES) and the second 5% albumin as a priming solution were compared. Hematocrit, platelet counts, plasma fibrinogen levels, postoperative drainage, prothrombin and partial thromboplastin time, urine output, and administration of blood products were investigated and compared. There were no differences in chest tube drainage, blood use, urine output, coagulation, and hematologic and hemodynamic parameters, except for an early postoperative increase in platelet count in the HES group. HES is a safe, effective, inexpensive volume expander in cardiac surgery patients.

Ten (0.28%) patients with anomalous origin of a coronary artery were detected from inspection of 3500 selected coronary arteriograms. In 1 patient the left main coronary artery (LMCA) originated from the pulmonary artery (PA). In 1 patient situs inversus totalis was present. This patient had a single coronary artery originating from the right coronary sinus. In 2 patients atrial septal defect (ASD) and aortic stenosis (AS) were additionally present. In 2 patients having an anomalously originated coronary artery, additional atherosclerotic coronary artery disease was present. In 4 patients coronary artery bypass grafting (CABG) operations were per formed. In 2 other patients ASD closure and aortic valve replacement (AVR) were performed. One patient with anomalous LMCA originating from the right coro nary sinus refused operation. There was no mortality or morbidity. All of the patients are symptom free and are having an active life.

There are various causes of the formation of arterial pseudoaneurysms, including trauma, surgical procedures, infection and iatrogenic injuries. A popliteal aneurysm was detected in a patient with pain and discomfort in his leg. The patient had a history of knee surgery. The aneurysm was treated surgically. Aneurysms following penetrating arterial injury resulting from surgical intervention requiring the use of surgical devices is one of the possible traumatic causes.

Background : Adhesions due to the reactions caused by the grafts used in the primary vascular operation can lead to various problems when a secondary operation is necessary. These problems include: bleeding, injuries to neighboring organs sand complications occurring due to a prolonged operation. We investigated the affects of sirolimus, which has antiproliferative effects on vascular adhesions. Methods : The abdominal aortae of rats were explored and abrasions inflicted. Following the fixation of a PTFE (Polytetra floroetilen) graft on the abdominal aorta, rapamycin (sirolimus) was applied (in powder form) on the grafts of the study group. Four weeks later a laparotomy was done and the adhesions developed were evaluated. Results : In the study group the adhesions were determined to be fewer in number and milder in severity. Severe adhesion were noted in the control group. Conclusions : Therefore, sirolimus applied around the prosthesis in vascular operations, was determined to be effective in preventing possible adhesions. Keywords : Sirolimus (Rapamycin), adhesion Nigerian Journal of Surgical Research Vol. 7(3&4) 2005: 285-289

Behcet hastaligi tum viseral arterleri tutabilen kronik ve tekrarlayan sistemik vaskulittir. Bu yazida Behcet hastaligi olan 37 yasinda erkek bir olgu, tekrarlayan viseral arter anevrizmasi ve cerrahi tedavi ile birlikte sunuldu. Anah tar soz cuk ler: Anevrizma; Behcet hastaligi; viseral arter. Behcet’s disease is a chronic, recurrent systemic vasculitis which can involve all visceral arteries. In this article, we present a 37-year-old male case with Behcet’s disease with recurrent visceral artery aneurysm and the surgical treatment.

Background: In approximately 50% of the patients who have undergone coronary artery bypass surgery (CABG), pleural fluid collection occurs at the early postoperative period and resolves spontaneously. Case Report: CABG was performed on a 54-year-old man. In the early postoperative period, the chest roentgenogram revealed right pleural collection. The preoperative and the postoperative hepatic function tests were normal. MR scanning revealed a giant hydatid cyst at the apex of the liver. The cyst was excised through thoracotomy transphrenically and primary capitonage was applied. Conclusions: In the persistent right pleural effusion that occurs after open heart surgery hydatid cyst of the liver should be remembered, especially in the endemic regions.

Reperfusion injury is a consequence of inadequate energy supply and acidosis in ischemic tissues and a chain of events triggered by oxygen-derived free radicals released in response to exposure of oxygen. In this study, we aimed to assess the effects of clopidogrel, an antithrombotic agent, on experimental ischemia-reperfusion model in rats. The ischemia was performed by blockade of the circulation of right lower extremity at trochanter major level for 6 hours. Then, the extremity was reperfused for 4 hours. Another group of rats pretreated with clopidogrel (0.2 mg/kg/day) for 10 days prior to ischemia-reperfusion. After the reperfusion period, all rats were anesthetized with ketamine. Blood and tissue samples from the gastrocnemius muscle, liver and lungs were taken for the measurement of malondialdehyde (MDA), glutathione (GSH) levels and superoxide dismutase (SOD) activity. The results revealed that clopidogrel prevented the increase in MDA level and the decrease in GSH level and SOD activity caused by ischemia-reperfusion both in tissue samples and plasma. These findings suggest that clopidogrel is beneficial in prevention of ischemia-reperfusion injury probably via its effects on inflammatory cells, platelets, and endothelial cells.

Peri-procedural Changes in Serum Arylesterase Acvitivity in Patients Undergoing Elective PCI for Stable CAD. H. Erman, H.A. Cakmak, B. Ikitimur, V. Sozer, Z. Ongen, B. Karadag, R. Gelisgen, G. Simsek, H. Uzun. Department of Biochemistry, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey; Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey; Department of Cardiology, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey; Department of Physiology, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey; Department of Biochemistry, Yildiz Technical University, Istanbul, Turkey. Introduction: Oxidative stress, characterized by an imbalance between the generation ROS and the capacity of the intrinsic antioxidant defense system, may be implicated in the pathogenesis of cardiovascular diseases. Percutaneous transluminal coronary angioplasty (PTCA) and stent deployment induce production of vascular reactive oxygen species (ROS) and reactive nitrogen species (RNS) leading to post-procedural pathophysiological changes including restenosis, stent thrombosis, and endothelial dysfunction. Previous studies suggest that oxidative stress plays an important role in the pathophysiology of restenosis. Because of the actual mechanism accounting for the increased oxidative stress formation in circulation among patients undergoing PCI is still undefined, we aimed to investigate through the analysis of a novel parameter, namely ARE activity, whether early changes in oxidative stress takes place in stable coronary artery disease (CAD) patients undergoing elective PCI with implantation of stents. Methods: In this study 32 consecutive chronic stable angina patients (mean age 61 9.8 years, 75% male) undergoing PCI for management

Purpose: We present the case of a patient who developed an aortoesophageal fistula (AEF) 4 years after thoracic endovascular aortic repair (TEVAR) of a descending thoracic aortic aneurysm rupture.Case Report: A 60-year-old female patient underwent emergency stent graft placement in December 2006 because of rupture of a distal descending aortic aneurysm. The patient was discharged uneventfully. Four years later, the patient was readmitted because of recurrent hematemesis, weight loss, and malaise. A computed tomography scan and an upper gastrointestinal system (GIS) endoscopy examination revealed an AEF located at the midportion of the esophagus and at the caudal end of the stent graft. An emergency stent graft was re-replaced into the previous graft. The patient died from hemorrhagic shock due to massive GIS bleeding while she was being prepared for secondary major esophageal surgery.Conclusion: AEF is a catastrophic complication of TEVAR. Conservative treatment is often associated with fatal results. If possible, these patients should be treated with secondary major surgical procedures.

Background Various types of markers have been used so far in order to reveal myocardial perfusion defect. However, these markers usually appear in the necrosis phase or in the late stage. Having been the focus of various investigations recently, ischemia-modified albumin (IMA) is helpful in establishing diagnosis in the early stages of ischemia, before necrosis develops. Methods and Results 30 patients that underwent only coronary bypass surgery due to ischemic heart disease within a specific period of time have been included in the study. IMA levels were studied in the preoperative, intraoperative, and postoperative periods. The albumin cobalt binding assay was used for IMA determination. Hemodynamic parameters (atrial fibrillation, the need for inotropic support, ventricular arrhythmia) of the patients in the postoperative stage were evaluated. Intraoperative measurement values (mean ± SD) of IMA (0.67677 ± 0.09985) were statistically significantly higher than those in the preoperative (0.81516 ± 0.08894) and postoperative (0.70477 ± 0.07523) measurements. Considering atrial fibrillation and need for inotropics, a parallelism was detected with the levels of IMA. Conclusions IMA is an early-rising marker of cardiac ischemia and enables providing a direction for the treatment at early phases.