Endovascular Repair and Adjunctive Immunosuppressive Therapy of Aortic Involvement in Behçet's Disease.

OBJECTIVES: Aortic aneurysm is a serious problem in Behçet's disease, but open surgical therapy carries the risk of recurrent pseudoaneurysm. Here the outcomes of endovascular repair and adjunctive immunosuppressive therapy for aortic disease in Behçet's disease are presented. MATERIALS: This was a retrospective study. Between 2002 and 2012, nine patients with Behçet's disease (8 male, median age 41 years, range 33-60 years) were treated by endovascular stent grafting for abdominal or thoraco-abdominal aortic pseudoaneurysm. METHODS: Computed tomography angiography revealed infrarenal pseudoaneurysm in six (66.6%) patients and suprarenal pseudoaneurysm in three (33.3%). Patients received immunosuppressive therapy with oral prednisolone (60 mg/day) and cyclophosphamide (200 mg/day) for 2 weeks or more before the procedure, and intravenous hydrocortisone (200 mg/day) combined with cyclophosphamide (200 mg/day) for 3 days after the procedure. Thereafter, oral immunosuppressive therapy was continued for 2 years. RESULTS: A straight tube graft was implanted in seven patients and a bifurcated graft in two patients. Two stage procedures (debranching before endovascular therapy) were performed in three patients for thoraco-abdominal aortic pseudoaneurysms. Stent grafting was successful in all patients, without any peri-operative complications. However, two patients needed abdominal exploration later: one for seroma around the graft and the other for a fistula between the duodenum and the graft. No recurrence of aneurysm was observed during a mean follow up of 40 ± 16 months. One patient died in the 15th month from a non-vascular cause. CONCLUSIONS: Endovascular stent graft implantation and adjunctive immunosuppressive therapy seems to be safe and effective in the treatment of aortic involvement in Behçet's disease, but this approach needs further evaluation.

Postoperative Outcomes of the Largest HeartMate-II Experience in Turkey.

INTRODUCTION: HeartMate II (HMII; Thoratec Corporation, Pleasanton, Calif, United States) is a continuous-flow pump approved by the Food and Drug Administration (FDA) for bridge-to-transplantation (BTT) since 2008 and for destination therapy (DT) since 2010. Herein, we present the postoperative outcomes of HMII implantation due to end-stage heart failure in our center. METHODS: Twenty-eight patients (mean age, 51.2 ± 8.7 years; 1 female) were implanted with the HMII between August 2012 and August 2014. Indications were dilated (n = 18) and ischemic (n = 10) cardiomyopathy. The intended treatment was BTT in 24 and DT in 4 patients. Preoperative clinical status was International Registry for Mechanical Circulatory Support (INTERMACS) 2, 3, and 4 in 6, 14, and 8 patients, respectively. The procedure was performed via conventional sternotomy under cardiopulmonary bypass. Heparin, acetylsalicylic acid, and warfarin were used for postoperative anticoagulation. RESULTS: Mean duration of support was 326 days (median, 272). Three patients underwent heart transplantation and 22 remain on pump support. One patient died before discharge due to respiratory failure and 2 others died following a cerebral bleeding 248 and 265 days postoperatively, respectively. The survival rates at 6 and 12 months were 96% and 90%, respectively. Temporary right ventricular failure was observed in 2 patients. Two patients had pump thrombosis treated with anticoagulation management or pump exchange, whereas another patient who had aortic root thrombosis underwent reoperation for removal of the thrombus. DISCUSSION: Mechanical circulatory support with HMII axial flow pump seems to be effective and may provide good survival rates compared with optimum medical management and old-generation devices. Patient selection and timing of implantation are crucial for success.

Long-term paracorporeal ventricular support systems: a single-center experience.

BACKGROUND: The Berlin Heart EXCOR is a first-generation paracorporeal, pneumatic ventricular assist device that creates pulsatile flow. It can be used for long-term support of the left and/or right ventricule during end-stage heart failure. The aim of this study was to share our clinical experience in 54 patients. METHODS: Between April 2007 and August 2012, 54 patients with end-stage heart failure underwent Berlin Heart EXCOR ventricular assist device implantation, including 5 females and 9 children. Twenty-four patients (44%) were in Intermacs level 1, 11 (21%) in level 2, and 19 (35%) in level 3. Biventricular support was applied to 13 patients. Device implantation was performed with an "on pump" beating heart technique while 6 other patients underwent intervention operations while the aortic valve has under cross-clamp. Tricuspid annuloplasty was performed in 6 patients. RESULTS: There was no peroperative death. Nine patients (17%) underwent re-exploration because of hemorrhage in the early postoperative period. Heart transplantation was performed in 32 patients (59%), while 10 (19%) are still under pump support with a mean follow-up of 13 months. Although 1 was successfully weaned from the system, 11 patients (20%) died during the support. Pump-head exchange was required 19 times in 17 patients because of visible thrombus or fibrin deposit in the pump head or due to membrane rupture. DISCUSSION: The use of long-term paracorporeal assist devices has decreased in recent years because of the increased popularity of implantable devices that permit longer survival and a better quality of life. We believe that the Berlin Heart EXCOR has a special role because it can be used in pediatric patients and especially in critical conditions like Intermacs levels 1 and 2.

Left ventricular assist device implantation in heart failure patients with a left ventricular thrombus.

BACKGROUND: In this report, we share our experience with left ventricular assist device (LVAD) implantation in cases with a left ventricular (LV) thrombus. METHOD: Over the 3 years, more than 100 end-stage heart failure cases have been treated with LVAD implantation in our center, including 6 patients with a LV thrombus. Three were detected using preoperative transthoracic echocardiography. Fifty percent of the patients had dilated cardiomyopathy and the remaining cases had an ischemic etiology. Double inotropic support with dopamine and dobutamine was used in all, with 3 drugs with the addition of adrenaline in 2 patients. In 4 cases we implanted the HeartWare Ventricular Assist System (HeartWare, Inc., Miramar, Fla, United States) and in the remaining 2 patients, the Berlin Heart EXCOR ventricular assist device (Berlin Heart AG, Berlin, Germany) for biventricular support. In 1 patient the apical ventriculotomy was extended to remove an intertrabecular thrombosis and ventricular septal surface covered with a dacron patch to minimize the thrombogenic potential. RESULTS: Two patients died due to sepsis and multiorgan failure. None of the patients experienced a neurological event, pump thrombosis, or pump malfunction. Two subjects underwent re-explorations due to hemorrhage. Two candidates underwent successfull transplantation without any evidence of thrombosis in the explanted heart or device. CONCLUSION: We believe that patients with a LV thrombus and preserved right ventricular function are good candidates for implantation of a LVAD after removing the intracavitary thrombus.

Effect of aortic valve movements on gastrointestinal bleeding that occured in continuous flow left ventricular assist device patients.

BACKGROUND: Gastrointestinal (GI) bleeding is one of the recently reported complications with continuous flow left ventricular assist devices (LVAD). The pathophysiology and etiology are unclear. We sought to describe the relationship between aortic valve movements and GI bleeding among patients with a new generation of LVAD. METHODS: We evaluated the data of 30 patients who underwent LVAD (HeartWare VAD) implantation from December 2010 to September 2012. The most common etiologic diagnosis was dilated cardiomyopathy. Patients were considered to show GI bleeding if they had hematemesis, melena, or hematochezia. RESULTS: Among 3 patients, 2 displayed upper GI bleeding and 1 had lower GI bleeding based on endoscopic and colononoscopic examinations. Pathological reports showed arteriovenous malformations in patients diagnosed with upper GI bleeding. The absence of aortic valve movements and a history of previous GI bleeding were significant risk factors (P = .021 and P = .007, respectively). CONCLUSION: In addition to aortic valve movements, we believe that a GI bleeding history was an equally important factor predisposing to this complication.

Evaluation of changes in quality of life among Turkish patients undergoing ventricular assist device implantation.

BACKGROUND: Ventricular assist device (VAD) application has become an increasingly common method to treatment end-stage heart failure. In this study we evaluated the effect of VAD implantation upon the quality of life among Turkish patients with end-stage heart failure. METHODS: Twenty-eight VAD implantation patients included 3 (10.7%) with biventricular support using the Berlin Heart Excor; 15 (53.6%), left ventricular support with the Berlin Heart Excor; and 10 (35.7%), Heartware implantation for left ventricular support. The Minnesota Living with Heart Failure Questionnaire (MLHFQ) and Short Form 36 (SF-36) Health Questionnaire were used to assess changes in the quality of life (QOL). RESULTS: Of the 28 patients, 2 were females (7.1%) and 26 were males (92.9%) of overall mean age of 44.6 ± 15.3 years (range, 8-66). Preoperative mean score of MLHFQ was significantly improved at 200.4 ± 147.4 days follow-up (72.8 ± 11.5 vs 13.7 ± 10.5; P < .05). SF-36 physical scores and mental scores were improved postoperatively (physical scores, 20.0 ± 24.4 vs 70.2 ± 19.9; mental scores, 38.4 ± 18.8 vs 73.9 ± 15.7; P < .05). No significant relation was observed between the postoperative scores of questionnaires and type of surgery. More improvement in postoperative MLHFQ scores was seen in patients younger than 45 years of age (P = .027). The severity of chronic heart failure (CHF) regressed from New York Heart Association (NYHA) class IV to NYHA class II in 26 and to NYHA class III in 2 patients (P = .000). CONCLUSION: The QOL among patients with end-stage heart failure improved dramatically soon after VAD implantation.

Comparison of caudal ropivacaine, ropivacaine plus ketamine and ropivacaine plus tramadol administration for postoperative analgesia in children.

BACKGROUND: The aim of this study was to compare the effect of single-dose caudal ropivacaine, ropivacaine plus ketamine and ropivacaine plus tramadol in children for postoperative pain management. METHODS: Following ethics committee approval and informed parental consent, 99 ASA PS I or II children, between 1 and 10 years of age, scheduled for elective inguinal hernia repair with general anaesthesia, were recruited. After induction of anaesthesia and placement of a laryngeal mask airway (LMATM), the patients were randomly divided into three groups to receive either caudal ropivacaine alone (0.4%, 2 mg x kg(-1)) in group R (n = 32) or ropivacaine (0.2%, 1 mg x kg(-1)) plus ketamine (0.25 mg x kg(-1)) in group RK (n = 33) or ropivacaine (0.2%, 1 mg x kg(-1)) plus tramadol (1 mg x kg(-1)) in group RT (n = 34) with a total volume of 0.5 ml x kg(-1). Systemic blood pressure (SBP and DBP), heart rate (HR), peripheral O2 saturation (SpO2), respiratory rate (RR), sedation and pain scores were recorded at 5, 10, 15 and 30 min, 1, 3, 4 and 6 h following recovery from anaesthesia. Pain was evaluated by Children's Hospital of Eastern Ontario Pain Scale, and sedation with a five-point sedation test. RESULTS: No difference was found regarding age, weight and duration of operation between the groups (P > 0.05). No patient experienced hypotension, bradycardia or respiratory depression. Duration of analgesia was longer in group RT (1377 +/- 204 min) than group R (1006 +/- 506 min) (P = 0.001). In the tramadol group, fewer patients required supplementary analgesics in the first 24 h (P = 0.005). Sedation scores were below 2 in all groups. Incidence of postoperative nausea and vomiting was higher in group RT (eight patients) and group RK (seven patients) than group R (one patient, P = 0.032). CONCLUSIONS: Ropivacaine (0.4%), ropivacaine (0.2%) plus ketamine (0.25 mg x kg(-1)) and ropivacaine (0.2%) plus tramadol (0.5 mg x kg(-1)) provided sufficient analgesia in children, but the duration of analgesia was longer in the RT group.