Robotic repair of atrial septal defect with partial pulmonary venous return anomaly: Our 5 year experience.

INTRODUCTION: Partial pulmonary venous return anomalies (PPVRA) were not considered as a good candidate for robotic surgery in early time of robotic cardiac surgery. In this study, we present our experience in patients undergoing robotic atrial septal defect (ASD) and PPVRA surgery. METHODS: Between November 2014 and January 2020, data of 21 patients underwent robotic ASD with PPVRA was collected. Inclusion criterion was presence of right-sided PPVRA with ASD. All operations were performed robotically. RESULTS: The mean age of patients was 26.7 ± 10.3 years. Seventeen patients (81%) had superior-caval ASD with supracardiac PPVRA and double-patch technique was used. Four patients had inferior-caval ASD with intracardiac PPVRA and single-patch technique was preferred. Cross-clamp time and cardiopulmonary bypass time were 92.8 ± 29.6 and 127.8 ± 38.1, respectively. There was no mortality. One patient had atrioventricular-block and required pacemaker. CONCLUSION: Robotic repair of ASD with PPVRA is feasible and effective method as an alternative to conventional surgery.

Early- and mid-term results of cryoablation of atrial fibrillation concomitant with robotic mitral valve surgery.

OBJECTIVE: Atrial fibrillation (AF) is the most common arrhythmia, which is also associated with mitral valve disease. Surgical ablation is still known to be an important procedure in restoring sinus rhythm (SR) concomitant with mitral valve surgery (MVS). In this study, we aimed to pres-ent our early- and mid-term result of AF cryoablation during robotic MVS. METHODS: Between November 2014 and January 2020, total 34 patients who underwent robotic MVS with concomitant AF ablation were ret-rospectively analyzed. Ten patients had a <1 year AF history, 14 had 1-5 years, and 10 had >5 years. The primary end point of the study was postoperative AF recurrence. RESULTS: Total 32 and 2 patients underwent mitral valve replacement and mitral valve repair, respectively. Mean aortic cross-clamp and cardio-pulmonary bypass times were 141.8±32.1 min and 196±25.6 min, respectively. The SR was restored with the removal of cross-clamp and cardiac junctional rhythm was observed in 29 (85.3%) and 5 (14.7%) patients, respectively. Two in-hospital deaths secondary to low cardiac output and hepatorenal failure were recorded. Among the rest, 24 (75%) patients were in SR, 6 (18.75%) in AF, and 2 (6.25%) in paced rhythm at discharge. CONCLUSION: Robotic cryoablation of AF during MVS is a feasible method with favorable early- and mid-term results.

Comparison of postoperative outcomes between robotic mitral valve replacement and conventional mitral valve replacement.

BACKGROUND: Robotic mitral valve surgery continues to become widespread all over the world in direct proportion to the developing technology. In this study, we aimed to compare the postoperative results of robotic mitral valve replacement and conventional mitral valve replacement. METHODS: A total of consecutive 130 patients who underwent robotic mitral valve replacement and conventional mitral valve replacement with full sternotomy between 2014 and 2020 were included in our study. All patients were divided into two groups: Group I, with 64 patients who underwent robotic mitral valve replacement and Group II, with 66 patients with conventional full sternotomy. General demographic data (age, gender, body weights, etc.), comorbidities (hypertension, diabetes mellitus, chronic obstructive pulmonary disease, peripheral artery disease, hyperlipidemia, etc.), intraoperative variables (cardiopulmonary bypass times, and cross-clamp times), postoperative ventilation times, drainage amounts, transfusion amount, inotropic need, revision, arrhythmia, intensive care and hospital stay times, and mortality were analyzed retrospectively. RESULTS: There was no significant difference between demographic data, such as age, gender, body kit index, and preoperative comorbid factors of both patient groups (p > .05). Cardiopulmonary bypass time (204.12 ± 45.8 min) in Group I was significantly higher than Group II (98.23 ± 17.8 min) (p < .001). Cross-clamp time in Group I (143 ± 27.4 min) was significantly higher than Group II (69 ± 15.2 min) (p < .001). Drainage amount in Group I (290 ± 129 cc) was significantly lower than Group II (561 ± 136 cc) (p < .001). The erythrocyte suspension transfusion requirement was 0.4 ± 0.3 units in Group I; it was 0.9 ± 1.2 units in Group II, and this requirement was found to be significantly lower in Group I (p = .014). While the mean mechanical ventilation time was 5.3 ± 3.9 h in Group I, it was 9.6 ± 4.2 h in Group II. It was significantly lower in Group I (p = .001). Accordingly, intensive care stay (p = .006) and hospital stay (p = .003) were significantly lower in Group I. In the early postoperative period, three patients in Group I and four patients in Group II were revised due to bleeding. In the postoperative hospitalization period, neurological complications were observed in one patient in Group I and two patients in Group II. Two patients in Group I returned to the sternotomy due to surgical difficulties. Two patients died in both groups postoperatively, and there was no significant difference in mortality (p = .97). CONCLUSION: According to conventional methods, robotic mitral valve replacement is an effective and reliable method since total perfusion and cross-clamp times are longer, drainage amount and blood transfusion need are less, and ventilation time, intensive care, and hospital stay time are shorter.

Unrecognized indication for robot-assisted cardiac surgery: Patients with acute psychotic disorders.

Patients with acute psychotic disorders are often considered as inappropriate candidates for cardiac surgery as well as for other surgical interventions. Post-operative care and patient compliance, which are the main problems associated with such patients, are the most important issues for conventional cardiac surgery. Robot-assisted cardiac surgery may be a new solution in this respect. In this report we aimed to present our acute psychotic patient with serious mitral insufficiency secondary to huge atrial myxoma, treated with robotic cardiac surgery.

Huge Intravascular Tumor Extending to the Heart: Leiomyomatosis.

Intravenous leiomyomatosis (IVL) is a rare neoplasm characterized by histologically benign-looking smooth muscle cell tumor mass, which is growing within the intrauterine and extrauterine venous system. In this report we aimed to present an unusual case of IVL, which is originating from iliac vein and extended throughout to right cardiac chambers. A 49-year-old female patient, who was treated with warfarin sodium due to right iliac vein thrombosis, was admitted to our department with intermittent dyspnea, palpitation, and dizziness. Physical examination was almost normal except bilateral pretibial edema. On magnetic resonance venography, there was an intravenous mass, which is originated from right internal iliac vein and extended into the inferior vena cava. Transthoracic echocardiography and transesophageal echocardiography revealed a huge mass extending from the inferior vena cava through the right atrium, with obvious venous occlusion. Thoracic, abdominal, and pelvic MR showed an intravascular mass, which is concordant with leiomyomatosis. Surgery was performed through median sternotomy. A huge mass with 25-cm length and 186-gr weight was excised through right atrial oblique incision, on beating heart with cardiopulmonary bypass. Histopathologic assessment was compatible with IVL. Exact strategy for the surgical treatment of IVL is still controversial. We used one-stage approach, with complete resection of a huge IVL extending from right atrium to right iliac vein. In such cases, high recurrence rate is a significant problem; therefore it should be kept in mind.

Oxaliplatin Induced Digital Ischemia and Necrosis.

Introduction. Digital ischemia is a rare complication of several chemotherapeutic medications. We aimed to present a patient with digital ischemia, secondary to a new generation chemotherapeutic drug, oxaliplatin. Case Report. 62-year-old woman presented to our department with severe pain, paresthesia, and distal acrocyanosis on her right hand fingertips. Her complaints started five days after the third cycle of a chemotherapy protocol consisting of 5-fluorourasil (5-FU), folinic acid, and oxaliplatin due to advanced colon carcinoma. On physical examination, hemorrhagic and partly ulcerative lesions were detected at her right hand fingertips. Radial and ulnar pulses were absent at affected side. Digital subtraction angiography revealed severe vascular resistance in the affected extremity. Iloprost trometamol treatment was started with the dosage of 1 ng/kg/min. In addition, low-molecule-weight heparin was used for preventing possible microemboli. Symptomatic relief was provided after five days, and patient was discharged on 7th day of treatment. Discussion. The pathogenesis of oxaliplatin induced vascular toxicity remains unclear. Endothelial damage, increased adherence of platelets, deposition of immune complexes as an immunologic effect of oxaliplatin, and hypercoagulable state may be the reason for arterial thrombosis, digital microemboli, possible digital ischemia, and their several consequences.

Preoperative frontal QRS-T angle is an independent correlate of hospital length of stay and predictor of haemodynamic support requirement following off-pump coronary artery bypass graft surgery.

OBJECTIVES: With the adoption of novel operative techniques and aggressive care protocols that facilitate earlier extubation and mobilization of patients, postoperative length of stay (LOS) following coronary artery bypass graft surgery (CABG) has declined. However, there is paucity of information regarding preoperative electrocardiographic predictors of LOS following CABG. In this study, we investigated whether frontal QRS-T angle, which is an abnormal repolarization marker in prediction of various cardiovascular events, was an independent correlate of postoperative hospital LOS for off-pump CABG. Furthermore, we evaluated independent predictors of vasopressor agent/intra-aortic balloon pump (IABP) support requirement following off-pump CABG. METHODS: In this observational study, 78 patients with stable angina, who were scheduled for elective coronary artery bypass surgery following diagnosis of obstructive coronary artery disease by conventional angiography, were enrolled. RESULTS: Left ventricular ejection fraction (LVEF) was significantly lower and vasopressor agent/IABP support requirement and incidence of sustained atrial or ventricular arrhythmias was higher in patients with wide QRS-T angle (P < 0.05). Postoperative hospital LOS was also longer in this group. From the preoperative characteristics, wide frontal QRS-T angle was found to be an independent correlate of postoperative hospital LOS (B ± SD: 11.97 ± 0.62, P ≤ 0.01). Wide frontal QRS-T angle was also found to be an independent predictor of vasopressor agent/IABP support requirement postoperatively (OR: 7.87, P ≤ 0.01). CONCLUSIONS: Prediction of the hospital LOS and patient outcome following CABG is of great importance. Being easily obtainable via standard 12-lead electrocardiogram and its low cost may make frontal QRS-T angle a beneficial marker for reducing both patient-based morbidity and economic burden.

How can follow-up of patients with Raynaud phenomenon be optimized?

BACKGROUND Raynaud phenomenon (RP) is common worldwide and presents diagnostic and therapeutic difficulties. We aimed to share our experience with optimizing of patient follow-up by using the cold-stimulation test (CST). MATERIAL AND METHODS Data of 81 patients admitted with RP symptomatology were collected. Demographic data and symptoms were recorded. A scale was used for determining the severity of disease at pre-treatment and post-treatment. CST was performed to all patients at pre-treatment and post-treatment for assessment of treatment efficiency in follow-up. Results were analyzed with the SPSS for Mac 20.0 program. RESULTS All the patients were male. Mean age was 22.3 ± 2.14 (19-29). Mean duration of symptoms from onset to present was 4.59 ± 2.85 years. There were statistically significant differences between pre-treatment and post-treatment hand temperatures measured by CST (p<0.001). However, there were no statistically significant differences between pre-treatment and post-treatment severity scores of patients (p=0.135). CONCLUSIONS To quantitatively determine the treatment efficacy, CST may be used instead of asking simple questions of patients.

Autonomic imbalance assessed by time-domain heart rate variability indices in primary Raynaud's phenomenon.

OBJECTIVES: The pathogenesis of primary Raynaud's phenomenon (RP) seems to be multifactorial and autonomic nervous dysfunction is one factor. Heart rate variability (HRV) is one of the most reliable parameters to demonstrate autonomic dysfunction. Our aim was to evaluate the time-domain HRV in patients with primary RP. METHODS: A time analysis of HRV was performed in patients with primary RP and age- and gender-matched healthy controls. The results of the study and control group were compared. RESULTS: Thirty patients with primary RP [all men, median (IQR) age: 21 (2) years) and 31 age- and gender-matched healthy controls (median (IQR): 21(3) years] were enrolled in the study. We found a statistically significant difference between the primary RP patients and control subjects in terms of time-domain HRV parameters (p < 0.05 for all). CONCLUSION: Our study showed the presence of autonomic nervous dysfunction of heart function in patients with primary RP.

Platelet indices may be correlated with severity of vasospastic disorders.

BACKGROUND Vasospastic disorders are common worldwide. In daily practice, routine blood samples are used for several investigations. In this study we aimed to determine the possible correlations between lymphocyte count, platelet indices, and the severity of vasospastic disorders. MATERIAL AND METHODS Data of 102 patients admitted to our department with vasospastic disorder symptomatology were retrospectively collected. Demographic data, symptoms, and blood test results were recorded. Patients were divided into 2 groups according to their rewarming time, which is determined by the cold stimulation test. Group 1 consisted of patients with rewarming time below 20 min and Group 2 consisted of patients with rewarming time above 21 min. Demographic data and blood test results were compared between groups. Results were analyzed with the SPSS for Mac 20.0 package program. RESULTS There was no statistically significant difference between the groups in demographic variables and symptomatology. In Group 2, mean platelet volume (MPV) and platelet distribution width (PDW) were higher than in Group 1, which was statistically significant (8.87 ± 0.74 vs. 8.38 ± 0.78, p=0.001 and 15.91 ± 1.92 vs. 14.7 ± 1.99, p=0.002, respectively). Similar to MPV and PDW, lymphocyte count was also higher in Group 2 than in Group 1 (2.28 ± 0.65 vs. 1.90 ± 0.68, p=0.002). CONCLUSIONS Diagnosis and grading the severity of VD is challenging, but it can be supported by the presence of increased PDW, MPV, and lymphocyte count.

Adding Doppler ultrasonography to the follow-up of patients with vasospastic disorder improves objectivity.

BACKGROUND: Assessing therapeutic efficacy and patient satisfaction objectively and quantitatively has always been a problem in patients with vasospastic disorders. We aimed to present the additive value of ultrasonographic assessment of peripheral arteries secondary to cold stimulation, as a test for treatment efficacy during follow-up. MATERIAL AND METHODS: Arterial blood flow rates were measured from radial artery with Doppler USG in patients who presented to our department with vasospastic disorders. Ultrasonography was performed at the following intervals; before cold stimulation and at 5th, 10th, 15th, 20th minutes of cold stimulation. Patients were controlled by repeat cold stimulation test and Doppler US at the 2nd month of the treatment. Results were analyzed with SPSS for Mac 20.0 package program. RESULTS: We enrolled 46 patients in the study. All patients were male and mean age was 22.3 ± 2.17 years. Most common symptoms were cyanosis and coldness. There were statistically significant differences between pre-treatment and post-treatment arterial blood flow rates at each measurement time point (p<0.001) except initial measurement (p>0.05). On post-treatment values, there were 10.04±0.78 cm/s increase in 5th minute, 6.25 ± 1.39 cm/s in 10th minute, 6.43 ± 2.13 cm/s in 15th minute, and 6.38 ± 1.86 cm/s in 20th minute measurements. All increases at the 5 time points were statistically meaningful when compared to their pre-treatment corresponding time points (p<0.001). CONCLUSIONS: Doppler flowmetry added to standard cold stimulation test for evaluating the patients with vasospastic disorders provides better and more objective results when compared to the patient-oriented subjective scoring systems.

Frontal planar QRS/T angle can be a prognostic factor in the early postoperative period of patients undergoing coronary bypass surgery.

BACKGROUND: Wide QRS/T angle reflects the ventricular repolarization heterogeneity and has been found in association with cardiac morbidity and mortality in various study populations. However, literature data about the availability of QRS/T angle in patients undergoing cardiac surgery has not yet been available. METHODS: A total of 157 patients who underwent isolated coronary artery bypass surgery were included in this study. A preoperative 12-lead ECG was obtained one day before surgical procedure. The absolute difference between the frontal QRS wave axes and T-wave axes was defined as frontal planar QRS/T angle. Afterwards, patients were divided into two groups according to their frontal planar QRS/T angle (the cut-off value as 90°). RESULTS: Group 1 consisted of 109 patients with frontal planar QRS/T angle of <90, and the remaining 48 patients with frontal planar QRS/T angle 90 were placed into group 2. Mean EuroSCORE was much higher in group 2. There were significant differences for positive inotropic agent usage (27.5% for group 1 versus 58.3% for group 2, P < .001) and the prevalence of postoperative atrial fibrillation (11.9% for group 1 versus 31.2% for group 2, P = .004) between the two groups. In multivariate logistic regression analysis, used to determine the independent predictors of positive inotropic usage in the early postoperative period, only frontal planar QRS/T angle (OR: 0.989, 95% CI: 0.981-0.997, P = .008) and EuroSCORE (OR: 0.792, 95% CI: 0.646-0.971, P = .025) were found to be statistically significant. CONCLUSION: We found that frontal planar QRS/T angle might be an important preoperative parameter in predicting the need for inotropic drugs in the early postoperative period following coronary artery bypass surgery.

Acute arterial thrombosis following chemotherapy in a patient with a gastric carcinoma.

The pathogenesis of in situ thrombosis in cancer patients is not well known. Possible factors include endothelial damage, decreasing levels of anticoagulant factors and increasing levels of pro-coagulants. In the literature, the incidence of arterial thrombosis in cancer patients is reported to be 3.8%; 5-fluorouracil is mentioned as a rare causative agent, whereas cisplatin is thought to be the most common agent responsible for in situ thrombosis. In this report we present a 43-year-old male patient with bilateral popliteal artery embolism after 5-fluorouracil/cisplatin/taxotare combination chemotheraphy for gastric carcinoma. He had no additional risk factors such as smoking or any persistent organic arterial disease. He had sinus cardiac rhythm on electrocardiography and there were no abnormalities on echocardiography that could have been source of emboli. Surgical thrombectomy was performed with effective anticoagulation. After the operation, our medical oncologist discontinued 5-fluorouracil. At follow up, there was no evidence of thrombosis, with normal vascular flow rate.

Multiple osteochondromatosis complicated with a popliteal artery pseudoaneurysm.

In this article, we present a 21-year-old male patient who presented with swelling and pain located to right lower thigh and knee. Physical examination and subsequent diagnostic work-up revealed a pseudoaneurysm associated with an osteochondroma at lower thigh. This complication should be considered in young patients with a mass at knee and lower thigh region.

Sodium nitrite and cardioprotective effect in pig regional myocardial ischemia-reperfusion injury model.

OBJECTIVES: The present study was designed to investigate the cardioprotective effect of sodium nitrite (NaNO2) and sodium nitrate (NaNO3) against myocardial ischemia-reperfusion (I/R) injury in a pig regional ischemia model. MATERIAL AND METHODS: Eighteen pigs were randomly divided into three groups as control (Group 1), sodium nitrite (Group 2) and sodium nitrate (Group 3) groups. Before the exploration of the heart, blood samplings were taken for alanine aminotranspherase (ALT), aspartate aminotranspherase (AST), lactate dehydrogenase (LDH), creatinine kinase-muscle band (CK-MB), troponin-t, glutathione peroxidase (GPx), superoxide dismutase (SOD), catalase (CAT), malondialdehyde (MDA) and nitrite/nitrate (NO2-/NO3-) in all groups (T0). Following sternotomy and stabilization, blood and tissue samples were repeated (T1). Then, intracoronary sodium nitrite and sodium nitrate were given (0.5µg/kg) in Groups 2 and 3. Five minutes later, the left anterior descending (LAD) artery was ligated for I/R experiments. Blood and tissue samplings were repeated after 60 minutes of ischemia (T2) and 180 minutes of reperfusion period (T3). Light and electron microscopic investigations were performed. RESULTS: There were statistically significant results in favor of Group 2 in all studied parameters. Hemodynamic parameters showed a decrease in mean arterial pressure (MAP), cardiac output (CO), cardiac index (CI) and an increase in heart rate, mean pulmonary artery pressure (MPAP), left ventricle end-diastolic pressure (LVEDP), pulmonary capillary wedge pressure (PCWP) during ischemia. Following the ischemia these parameters returned to their near normal levels. This was prominent in group 2. Oxidative parameters showed protective increases in GPx, SOD, CAT and NO2-/NO3- levels and a decrease at MDA both in tissue and blood samples in group 2. There were statistical differences only in T3 for AST, troponin-t and CK-MB levels in favor of Group 2. Histological and electron microscopy examinations were also in favor of NO2- group. CONCLUSIONS: The results of the present study indicate that NaNO2 provides protection against myocardial I/R injury when compared to control and NaNO3 groups.