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Effect of systemic inflammation in the cardiac surgery performed on elderly/Yaslilarda yapilan acik kalp cerrahisinde sistemik enflamasyonun etkisi.

We would like to congratulate the authors for their study (1). Certainly, human life-span is being prolonged and mean age of the persons undergone cardiac surgery increased in parallel with increase of the quality of life. In this context, cardiac surgery in elderly has become a popular subject. Contrary to general belief, in parallel with the study by Kara et al. (1) many studies report that outcomes of the open heart surgeries performed on the patients with an advanced age were not poor (2, 3). However, we would like to specify that we have some questions regarding this issue. In many studies, inflammatory response is stated to increase in advanced ages (3-5). In relation to that, since one of the factors affecting open-heart surgery is known to be systemic inflammatory response, which is induced by open heart surgery itself, are not these outcomes expected to be poorer if this response is greater in elderly people? We would like to know authors' opinion on this point.

Another issue we would like to mention is that in a similar study, it was reported that open surgery outcomes were influenced from the blood amount which is preoperatively used in the people younger than 80 years old, but this negative effect was not observed in the patients in mid-eighties (3). We believe that it will add value to study of Kara et al. (1), if they have any data related to this interesting result.

Orhan Gokalp, Serkan Yazman (1), Barcin Ozcem (2), Ali Gurbuz Department of Cardiovascular Surgery, Faculty of Medicine, Katip Celebi University, Izmir-Turkey

(1) Clinic of Cardiovascular Surgery, Ataturk Education and Research Hospital, Izmir-Turkey

(2) Department of Cardiovascular Surgery, Faculty of Medicine, Yakin Dogu University, Lefkose-Cyprus


(1.) Kara I, Ay Y, Koksal C, Aydin C, Yanartas M, Yildirim T. The quality of life after cardiac surgery in octogenarians and evaluation of its early and mid-term results. Anadolu Kardiyol Derg 2012; 12: 352-8.

(2.) Sen B, Niemann B, Roth P Aser R, Schonburg M, Boning A. Short- and long-term outcomes in octogenarians after coronary artery bypass surgery. Eur J Cardiothorac Surg 2012; 42: e102-7. [CrossRef]

(3.) Yun JJ, Helm RE, Kramer RS, Leavitt BJ, Surgenor SD, DiScipio AW, et al. Limited blood transfusion does not impact survival in octogenarians undergoing cardiac operations. Ann Thorac Surg 2012; 94: 2038-45. [CrossRef]

(4.) Sansoni P Vescovini R, Fagnoni F Biasini C, Zanni F Zanlari L, et al. The immune system in extreme longevity. Exp Gerontol 2008; 43: 61-5. [CrossRef]

(5.) Zanni F Vescovini R, Biasini C, Fagnoni F Zanlari L, Telera A, et al. Marked increase with age of type 1 cytokines within memory and effector/cytotoxic CD8+T cells in humans: a contribution to understand the relationship between inflammation and immunosenescence. Exp Gerontol 2003; 38: 981-7. [CrossRef]

Address for Correspondence/Yazisma Adresi: Dr. Orhan Gokalp

Altinvadi cad. No:85 D:10 35320 Narlidere, Izmir-Turkiye

Phone: +90 505 216 88 13


Available Online Date/Cevrimici Yayin Tarihi: 22.04.2013

doi: 10.5152/akd.2013.119

Author's Reply

Dear Editor,

We read the letter to the Editor concerning our article titled "The quality of life after cardiac surgery in octogenarians and evaluation of its early and mid-term results". We are grateful to the authors' interest in the subject and for their critiques.

Whether or not an octogenarian, all patients who underwent cardiopulmonary bypass (CPB) suffer from the SIRS induced by contact of blood with non-physiological surfaces during CPB, surgical trauma, ischemia-reperfusion in various organs, changes in body temperature, complement activation, endotoxin, leucocyte activation as a result of release of cytokine and adhesion molecules, free oxygen radicals, arachidonic acid metabolites, platelet activating factor, and formation of substances like nitric oxide and endothelin. This resulting SIRS is a defense mechanism created to protect the organism in situations caused by mentioned pathological stimuli (1). The most important subject here is the severity of systemic inflamatory response during CPB and its' damage on organs. If, activated as a natural defense mechanism, SIRS, continues by uncontrolled activation of different humoral and cellular paths it is named as (SIRS), a pathological condition. And this condition can induce a rather complex, very difficult-to-control clinical process that can present with 90% mortality. Clinically, inflammatory response as a result of SIRS is observed in the form of myocardial failure, shortness of breath, nephritic and neurological system disorders, bleeding disorders, and multi-organ failure like hepatic disorders during the postoperative period (2). SIRS incidence is reported at 2% in all cases who underwent CPB (3). There are many factors triggering SIRS incidence during CPB and these triggering factors may create different responses in every patient (4). It was reported that the cause of this different response could be the different activation or damage of triggering factors on the endothelium (2).

In summary, as we have mentioned above, SIRS occurs as a result of many factors and the severity of the resulting inflammatory response can be different in persons with the same clinical symptoms. More importantly, there is no consensus on a biochemical parameter considered to show systemic inflammatory response clearly and as correctly as in nephritic dysfunction, diabetes, and atherosclerosis. However, patients with high risk profiles (e.g. multiple comorbidity, diabetes, low functional capacity) and a risk SIRS occurrence can be detected. However, a study conducted by Litmathe et al. (2) report SIRS rate to be 11% even in patients in the high risk group for which they considered a potential risk of perioperative SIRS occurrence. Therefore, uncontrolled humoral and cellular activation secondary to different endothelial effects and damage of increased inflammatory response with old age in situations such as diabetes, hypertension, hypercholesterolemia or nicotine addiction, which are specific risk factors for atherosclerosis, can lead to the occurrence of SIRS.

As a result, we do not agree with the authors' opinions that the outcomes should have been worse in octogenarian patients based on the factors we tried to explain above. Nonetheless, mortality is reported to be 12.5% in our article (5). As suggested in our article, patients with high risks of perioperative SIRS occurrence can in fact be detected and early mortality and morbidity reduced with a detailed analysis of the preoperative physiological and functional conditions of patients, comorbid diseases, and myocardial functions.

Ibrahim Kara

Clinic of Cardiovascular Surgery, Goztepe Safak Hospital, Istanbul-Turkey


(1.) Paparella D, Yau TM, Young E. Cardiopulmonary bypass induced inflammation: pathophysiology and treatment. An update. Eur J Cardiothorac Surg 2002; 21: 232-44. [CrossRef]

(2.) Litmathe J, Boeken U, Bohlen G, Gursoy D, Sucker C, Feindt P Systemic inflammatory response syndrome after extracorporeal circulation: a predictive algorithm for the patient at risk. Hellenic J Cardiol 2011;52:493-500.

(3.) Asimakopoulos G. Systemic inflammation and cardiac surgery: an update. Perfusion 2001; 16: 353-60. [CrossRef]

(4.) Engel C, Brunkhorst FM, Bone HG, Brunkhorst R, Gerlach H, Grond S, et al. Epidemiology of sepsis in Germany: results from a national prospective multicenter study. Intensive Care Med 2007; 33: 606-18. [CrossRef]

(5.) Kara I, Ay Y, Koksal C, Aydin C, Yanartas M, Yildirim T. The quality of life after cardiac surgery in octogenarians and evaluation of its early and mid-term results. Anadolu Kardiyol Derg 2012; 12: 352-8.

Address for Correspondence/Yazisma Adresi: Dr. Ibrahim Kara

Goztepe Safak Hastanesi, Kalp Damar Cerrahisi Klinigi, Fahrettin Kerim Gokay Cad. No:192, Kadikoy, Istanbul-Turkiye

Phone: +90 216 565 44 44-1050

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Article Details
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Author:Gokalp, Orhan; Yazman, Serkan; Ozcem, Barcin; Gurbuz, Ali
Publication:The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi)
Article Type:Letter to the editor
Date:Jun 1, 2013
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