C-reactive protein to albumin ratio provides important long-term prognostic information in patients undergoing endovascular abdominal aortic repair.

BACKGROUND: The prognostic value of C-reactive protein/albumin ratio (CAR) is of import in cardiovascular diseases. Our aim was to evaluate the impact of the CAR in patients with asymptomatic abdominal aortic aneurysm (AAA) undergoing endovascular aneurysm repair (EVAR). MATERIAL AND METHOD: We retrospectively evaluated 127 consecutive patients who underwent technically successful elective EVAR procedure between December 2014 and September 2020. The optimal CAR cut-off value was determined by using receiver operating characteristic (ROC) curve analysis. Based on the cut-off value, we investigated the association of CAR with long-term all-cause mortality. RESULTS: 32 (25.1%) of the patients experienced all-cause mortality during a mean 32.7 ± 21.7 months' follow-up. In the group with mortality, CAR was significantly higher than in the survivor group (4.63 (2.60-11.88) versus 1.63 (0.72-3.24), p < 0.001). Kaplan-Meier curves showed a higher incidence of all-cause mortality in patients with high CAR compared to patients with low CAR (log-rank test, p < 0.001). Multivariable Cox regression analysis revealed that glucose ≥ 110 mg/dL (HR: 2.740; 95% CI: 1.354-5.542; p = 0.005), creatinine ≥ 0.99 mg/dL (HR: 2.957, 95% CI: 1.282-6.819, p = 0.011) and CAR > 2.05 (HR: 8.190, 95% CI: 1.899-35.320, p = 0.005) were the independent predictors of mortality. CONCLUSION: CAR was associated with a significant increase in postoperative long-term mortality in patients who underwent EVAR. Preoperatively calculated CAR can be used as an important prognostic factor.

A simplified acute kidney injury predictor following endovascular aortic repair: ACEF score.

OBJECTIVES: Treatment of abdominal aortic aneurysms (AAA) with endovascular aortic repair (EVAR) has become quite common in recent years. This method, which has many advantages compared to the open surgical procedure, also has some complications. One of these complications is acute kidney injury (AKI). ACEF (age, creatinine, and ejection fraction) score, which is gaining popularity, can be an easy-to-use and cost-effective method in detecting this condition that causes increased morbidity and mortality. We aimed to evaluate whether this ACEF score may predict a development of AKI in patients who underwent EVAR. METHODS: A total of 133 consecutive patients with AAA who underwent EVAR were analyzed. The primary endpoint of the study was the development of AKI. The best cut-off value for the ACEF score to predict the development of AKI was calculated and according to this value, the patients were divided into two groups as those with high ACEF scores and those with low ACEF scores. ACEF score was calculated by the formula of age/EF + 1 (if baseline creatinine > 2 mg/dL). RESULTS: After the exclusion criteria, a total of 118 patients were included in the study, and 20 (16.9%) of them developed AKI after EVAR. In the ROC curve analysis, a cut-off value of 1.34 was found for the ACEF score, and scores above this value were found to be independent predictors of AKI development after EVAR. In addition to the ACEF score, the contrast media volume was also found to be an independent predictor of the development of AKI. CONCLUSION: In conclusion, ACEF is a simple and effective scoring system in patients undergoing EVAR. To the best our knowledge, our study is the first study which applies ACEF score to predict AKI in EVAR patients.

Comparison of Postoperative Outcomes of Sutureless versus Stented Bioprosthetic Aortic Valve Replacement

Abstract Objective: Sutureless aortic valve replacement (Su-AVR) offers an alternative to supra-annular stented biological aortic prostheses. This single-center study aimed to compare early outcomes after aortic valve replacement with sutureless and conventional stented bioprostheses. Methods: In this retrospective study, we analyzed 52 patients who underwent aortic valve replacement with sutureless and stented bioprostheses between January 2013 and October 2017. Sorin Perceval S sutureless valves were implanted in group 1 and Sorin Mitroflow stented bioprosthetic valves were used in group 2. Postoperative outcomes, including demographics, cardiopulmonary bypass (CPB) times, cross-clamp times, morbidity and mortality, as well as echocardiography in the first month, were compared. Results: Mortality occurred in 1 (3.6%) patient in group 1, and in 2 (8.3%) patients in group 2 (P=0.186). Group 1 had significantly shorter CPB (61.6±26.1 min vs. 106.3±32.7 min, P=0.001) and cross-clamp (30.9±13.6 min vs. 73.3±17.3 min, P=0.001) times. The length of stay in the intensive care unit (1.9±1.3 days vs. 2.4±4.9 days, P=0.598) and hospital stay (7.6±2.7 days vs. 7.3±2.6 days, P=0.66) were similar. Postoperatively, there was no statistically significant difference between the two groups in echocardiography results, and morbidities. The mean aortic valve gradient was 13.5±5.8 mmHg in group 1 and 14.5±8.0 mmHg in group 2 (P=0.634). Paravalvular regurgitation was diagnosed in 3 (10.7%) patients in group 1 and in 1 (4.2%) patient in group 2 (P=0.220). Conclusions: Su-AVR resulted in shorter cross-clamp and CPB times. However, early mortality, postoperative morbidity, and echocardiography results were similar between groups.

Rhythm disorders after isolated mitral valve surgery: Consideration of the variations of the sinoatrial nodal artery in choice of atriotomy.

Background: This study aims to investigate the effect of atriotomy approaches applied in mitral valve surgery and variations of the sinoatrial nodal artery on postoperative arrhythmias and the need for a temporary or permanent pacemaker. Methods: Data of 241 patients (108 males, 133 females, mean age: 53.7±12.3 years; range, 18 to 82 years) who underwent isolated mitral valve surgery with a median sternotomy between January 2009 and December 2019 were retrospectively analyzed. The patients were divided into three groups according to the surgical approach for mitral valve exploration as left atriotomy (n=47), transseptal (n=131), and superior transseptal (n=63). By scanning the hospital records, the origin of the sinoatrial nodal artery was determined in the coronary angiography images obtained before surgery. Postoperative rhythm changes were analyzed based on electrocardiography and telemetry recordings. Results: Temporary pacing was required in 31 (49.2%) patients in the superior transseptal group, 40 (30.5%) patients in the transseptal group, and 12 (25.5%) patients in the left atriotomy group, indicating a statistically significantly higher rate in the superior transseptal group (p=0.013). Permanent pacemaker implantation was required in only one patient (superior transseptal), indicating no significant difference among the groups. The first-degree atrioventricular block was seen in 28 (44.4%) patients in the superior transseptal group, 42 (32.1%) patients in the transseptal group, and 13 (27.7%) patients in the left atriotomy group (p=0.130). The PR interval in the postoperative period was longer in the superior transseptal group than in the left atriotomy group in patients with the sinoatrial nodal artery originating from the right coronary artery (p=0.049). No significant difference was observed among the surgical approaches regarding the PR interval in patients with the sinoatrial nodal artery originating from the left circumflex coronary artery after surgery. Conclusion: We believe that the choice of atriotomy in isolated mitral valve surgery and sinoatrial nodal artery variations do not affect permanent arrhythmia alone. Still, the superior transseptal approach causes the electrical conduction to slow down temporarily more than the left atriotomy and transseptal method.

Comparison of Postoperative Outcomes of Sutureless versus Stented Bioprosthetic Aortic Valve Replacement.

OBJECTIVE: Sutureless aortic valve replacement (Su-AVR) offers an alternative to supra-annular stented biological aortic prostheses. This single-center study aimed to compare early outcomes after aortic valve replacement with sutureless and conventional stented bioprostheses. METHODS: In this retrospective study, we analyzed 52 patients who underwent aortic valve replacement with sutureless and stented bioprostheses between January 2013 and October 2017. Sorin Perceval S sutureless valves were implanted in group 1 and Sorin Mitroflow stented bioprosthetic valves were used in group 2. Postoperative outcomes, including demographics, cardiopulmonary bypass (CPB) times, cross-clamp times, morbidity and mortality, as well as echocardiography in the first month, were compared. RESULTS: Mortality occurred in 1 (3.6%) patient in group 1, and in 2 (8.3%) patients in group 2 (P=0.186). Group 1 had significantly shorter CPB (61.6±26.1 min vs. 106.3±32.7 min, P=0.001) and crossclamp (30.9±13.6 min vs. 73.3±17.3 min, P=0.001) times. The length of stay in the intensive care unit (1.9±1.3 days vs. 2.4±4.9 days, P=0.598) and hospital stay (7.6±2.7 days vs. 7.3±2.6 days, P=0.66) were similar. Postoperatively, there was no statistically significant difference between the two groups in echocardiography results, and morbidities. The mean aortic valve gradient was 13.5±5.8 mmHg in group 1 and 14.5±8.0 mmHg in group 2 (P=0.634). Paravalvular regurgitation was diagnosed in 3 (10.7%) patients in group 1 and in 1 (4.2%) patient in group 2 (P=0.220). CONCLUSIONS: Su-AVR resulted in shorter cross-clamp and CPB times. However, early mortality, postoperative morbidity, and echocardiography results were similar between groups.

Novel markers of ventricular repolarization are associated with mortality in patients undergoing surgical aortic valve replacement for severe aortic stenosis.

INTRODUCTION: Aortic stenosis (AS) is the most common degenerative valvular heart disease that can affect left ventricular functions. Tp-e interval and Tp-e/QT ratio is a novel repolarization marker which is associated with adverse cardiovascular events in several cardiovascular diseases. In our study, our aim is to investigate the prognostic effect of Tp-e interval, Tp-e/QT and Tp-e/QTc ratios on mortality in patients who underwent successful surgical aortic valve replacement (AVR). METHODS: A total of three hundred seventy-five patients undergoing successful surgical AVR were included in this study. Then, patients were divided into two groups according to mortality as group 1 without mortality (342 patients) and group 2 with mortality (33 patients). Tp-e interval, Tp-e/QT, and Tp-e/QTc ratios were calculated for both groups. RESULTS: Tp-e interval (71 (63.7-77); 86 (84-88), p < .001), Tp-e/QT ratio (0.19 (0.17-0.20); 0.23 (0.22-0.23), p < .001) and Tp-e/QTc ratio (0.17 ± 0.02; 0.21 ± 0.01, p < .001) were higher in group 2 compared to group 1. In multivariate logistic regression analyses Tp-e interval (odds ratio [OR]: 1.315, 95% confidence interval [CI]: 1.203-1.437, p < .001), Tp-e/QT ratio (OR: 7.334, 95% CI: 3.274-1.643, p < .001) and Tp-e/QTc ratio (OR: 2.567, 95% CI: 4.106-1.605, p < .001) were found to be independent predictors of mortality. Additionally, a Kaplan-Meier survival analysis also revealed that long term survival was found to be significantly decreased in patients with higher Tp-e/QT ratio (Log-Rank p < .001) and Tp-e/QTc ratio (Log-Rank p < .001). CONCLUSION: Tp-e interval, Tp-e dispersion, Tp-e/QT, and Tp-e/QTc ratios are associated with worse prognosis after surgical AVR in patients with severe AS. All of them are also independent predictors of mortality.

Malnutrition provides important long-term prognostic information in patients undergoing endovascular abdominal aortic aneurysm repair.

OBJECTIVES: Malnutrition has been shown to be associated with survival in a variety of diseases. Our aim is to evaluate the prognostic value of objective nutritional indexes indicating malnutrition, in patients underwent endovascular aortic replacement. METHODS: We retrospectively evaluated 149 consecutive patients who underwent technically successful endovascular aortic replacement operation between October 2010 and August 2019. Objective nutritional indexes, prognostic nutritional index, geriatric nutritional risk index and controlling nutritional status, scores were calculated using the preoperative data. Optimal cut-off values were obtained by receiver operating characteristic analysis. According to the cut-off values, we investigated the relationship between indexes and the long-term all-cause mortality. RESULTS: During mean 48.0 ± 30.3 months follow-up duration, in 47 of patients (31.5%), all-cause mortality were documented. In mortality group, prognostic nutritional index (42.8 ± 7.1 vs 51.3 ± 5.2, p < 0.001) and geriatric nutritional risk index (100.7 ± 10.1 vs 107.6 ± 9.2, p < 0.001) were significantly lower, controlling nutritional status score (2.0 (1.0-4.0) vs 1.0 (0.0-2.0), p < 0.001) was higher when compared to survivor group. Kaplan-Meier curves presented higher mortality incidence in malnutrition patients evaluated with objective nutritional indexes (Log-rang test, for all three indexes p < 0.001). Besides Cox-proportional hazard analysis showed all three nutritional indexes may be a predictive marker for all-cause mortality, prognostic nutritional index introduced more valuable data than other two indexes. CONCLUSIONS: Malnutrition is associated with significant increase in postoperative long-term mortality in endovascular aortic replacement patients. Preoperatively calculated objective nutritional indexes especially prognostic nutritional index can be used as an important prognostic tool.

Rapidly Progressive Malignant Fibrous Histiocytoma of Right Atrium: a Rare Case Report.

We are going to present a case of malignant fibrous histiocytoma in the right atrium, which is a very rare entity. The patient had a right atrial mass, which prolapsed through the tricuspid valve into the right ventricle, causing functional tricuspid valve stenosis. The tumor was completely resected and the patient had an uneventful postoperative period. Histopathological examination reported malignant fibrous histiocytoma. The patient presented to the emergency department five weeks after discharge with dyspnea and palpitation. Echocardiography and magnetic resonance imaging revealed recurrent right atrial tumor mass. His clinical status has worsened, with syncope and acute renal failure. On the repeated echocardiography, suspected tumor recurrence was observed in left atrium, which probably caused systemic embolization. Considering the aggressive nature of the tumor and systemic involvement, our Heart Council decided to provide palliative treatment by nonsurgical management. His status deteriorated for the next few days and the patient succumbed to a cardiac arrest on the 4th day.

The role of the angle of the ascending aortic curvature on the development of type A aortic dissection: ascending aortic angulation and dissection.

OBJECTIVES: Type A aortic dissection (TAD), which consists of an intimal tear in the aorta, necessitates emergency surgery. Various risk factors related to aortic dissection have been defined in the literature. According to our hypothesis, a narrower angle of ascending aortic curvature (AAAC) may be an additional risk factor in relation to aortic dissection due to the increased force applied to the aortic wall. METHODS: Patients undergoing ascending aortic surgery due to an ascending aortic aneurysm (AsAA) (n = 105) and patients undergoing such surgery because of the occurrence of TAD (n = 101) were enrolled in this study. The AAAC was measured using Cobb's method; the measurements were made on all patients by just 1 cardiovascular radiologist using 3-dimensional computerized tomographic imaging. This measurement was made indirectly by using the aortic valve and brachiocephalic artery to avoid obtaining misleading data as a result of distortions due to dissection. A statistical comparison was also performed relating the traditional risk factors for TAD to other clinical and echocardiographic parameters: the diameter of the ascending aorta and the AAAC. RESULTS: The AAAC was found to be narrower statistically in the TAD group (α = 76.2° ± 17.5°) than it was in the AsAA group (α = 92.9° ± 13°) (P < 0.001). Furthermore, mean ascending aortic diameter (P = 0.019), the presence of a bicuspid aorta (P = 0.007) and aortic valve stenosis (P = 0.005) were higher in the AsAA group. According to multivariable analyses, a narrower AAAC is a significant predictor for the development of TAD (odds ratio 0.93, 95% confidence interval 0.91-0.95; P < 0.001). Overall hospital mortality from various causes including stroke, myocardial infarction, bleeding or renal failure was 13% in the TAD group and 7% in the AsAA group. CONCLUSIONS: According to this study, the AAAC was significantly smaller in aortic dissection patients than in aortic aneurysm patients. This may be related to higher shear stress and elevated pressure on the ascending aorta in patients with a narrower AAAC. Thus, a narrower AAAC may be an additional risk factor in the development of TAD. Therefore, we may need to be more careful in terms of looking for the development of aortic dissection in patients with narrower AAAC.

Rapidly progressive malignant fibrous histiocytoma of right atrium: a rare case report

Abstract We are going to present a case of malignant fibrous histiocytoma in the right atrium, which is a very rare entity. The patient had a right atrial mass, which prolapsed through the tricuspid valve into the right ventricle, causing functional tricuspid valve stenosis. The tumor was completely resected and the patient had an uneventful postoperative period. Histopathological examination reported malignant fibrous histiocytoma. The patient presented to the emergency department five weeks after discharge with dyspnea and palpitation. Echocardiography and magnetic resonance imaging revealed recurrent right atrial tumor mass. His clinical status has worsened, with syncope and acute renal failure. On the repeated echocardiography, suspected tumor recurrence was observed in left atrium, which probably caused systemic embolization. Considering the aggressive nature of the tumor and systemic involvement, our Heart Council decided to provide palliative treatment by nonsurgical management. His status deteriorated for the next few days and the patient succumbed to a cardiac arrest on the 4th day.

Comparison of patient-prothesis mismatch after surgical aortic valve replacement and transcatheter aortic valve implantation.

BACKGROUND: The aim of this study is to analyze the outcomes and incidence of postoperative patient-prothesis mismatch after surgical aortic valve replacement using supra-annular bioprosthesis and transcatheter aortic valve implantation. METHODS: Between January 2012 and June 2015, a total of 73 patients (37 males, 36 females; mean age 71.8±5.7 years; range, 65 to 82 years) who underwent either surgical aortic valve replacement using supraannular bioprosthesis (n=36) or transcatheter aortic valve implantation (n=37) were included. Postoperative patient-prothesis mismatch was defined as absent, mild-to-moderate, and severe, if the indexed effective orifice area was >0.85 cm2/m2, >0.65 to <0.85 cm2/m2, and <0.65 cm2/m2, respectively. Both groups were compared in terms of patient-prothesis mismatch, postoperative outcomes, and mortality. RESULTS: The overall incidence of mild-to-moderate patient-prosthesis mismatch was 17.8% (13/73). No severe patient-prosthesis mismatch was observed. Mild-to-moderate patient-prosthesis mismatch was found in three patients (8.1%) in the transcatheter group and in 10 patients (27.8%) in the surgery group (p=0.035). Body surface area was the significant predictor of patient-prosthesis mismatch (p=0.007). Diameters of bioprosthetic valves in the surgery and transcatheter groups were 21.4±2 and 23.9±2.6 mm, respectively (p=0.002). Early mortality and pacemaker implantation rates were higher in the transcatheter group (p>0.05). Postoperative outcomes were similar between the groups. Mid-term mortality at a mean follow-up of 47.7±7.3 months was similar between the groups (p=0.158). CONCLUSION: In high-risk patients with severe aortic stenosis, patientprosthesis mismatch is mild-to-moderate after surgical aortic valve replacement and transcatheter aortic valve implantation; however, this has no effect on early mortality. Based on our study results, we suggest that the use of surgical approach for aortic valve replacement may prevent potential complications of transcatheter aortic valve implantation.

Soft-tissue osteoma of the thenar eminence.

The development of osteoma in soft tissues without a direct contact with the adjacent osseous and articular structures is a very rare event. The involvement of the hand is even rarer, with only two previous cases reported so far. A 25-year-old man presented with a painless solid mass in the thenar region of his right palm, which appeared almost 2 years ago and showed a progressive enlargement in the last months. Under regional anesthesia an excisional biopsy was performed and the histopathological evaluation of the lesion confirmed the diagnosis of soft tissue osteoma. The postoperative follow-up period was uneventful without any complication or recurrence. Following a brief period of hand physiotherapy the patient has returned to normal daily activities.

A New Perspective for Spreader Graft Use in Severely Deviated Septum: Is Septal Continuity an Obligation for a Stable and Straight Nasal Septum?

Severe septal deviation is a challenging deformity usually treated using aggressive surgical methods, and extracorporeal septoplasty (ECS) is a commonly used method for this issue. However, this method has severe risks and complications such as the recurrent deformity or nasal saddling. In this article, we present an alternative solution to ECS procedure for the correction of severe septal deviation. Sixteen patients with severe c- or s-shaped septal deviation with a mean age of 26.5 years were included in the study. The entire deviated part of the septal cartilage was resected as a vertical block creating a full-thickness defect between the most cranial and caudal parts of the septal cartilage. After that, two spreader grafts were placed bilaterally facilitating the septal integrity and leaving the full-thickness septal defect unchanged. The surgical results were evaluated using the preoperative and postoperative facial photographs and patient satisfaction was determined using nine relevant questions of DAS-59 scale. The only complication observed in the follow-up period of 19 months was hanging columella deformity which was corrected at the postoperative first year. The mean length of the resected septal segment was 12.4 mm. The mean length of the resultant septal cartilage defect after the vertical resection was 5.9 mm. The mean length of the placed spreader grafts was 25.6 mm. The comparison of the preoperative and postoperative photographs showed significant improvement of the nasal contour and considerable correction of the septal deviation. The statistical evaluation of the answers given to the questions of the DAS-59 scale clearly demonstrates that a significant degree of patient satisfaction was achieved. Severe septal deviation may be successfully corrected by full-thickness resection of the deviated part and reconstruction with bilateral spreader grafts with a low risk of postoperative complications.

Altered expression of micro-RNA 199a and increased levels of cardiac SIRT1 protein are associated with the occurrence of atrial fibrillation after coronary artery bypass graft surgery.

BACKGROUND: Postoperative atrial fibrillation (POAF) is a potentially life-threatening complication after coronary artery bypass graft (CABG) surgery. The expression of the cardioprotective SIRT1 protein with its antioxidant activity is increased in cardiac tissue of patients suffering from POAF. So far, information is lacking about the relationship between SIRT1 regulating micro RNAs (miRs), SIRT1 protein and the occurrence of POAF. METHODS: A total of 63 patients undergoing CABG were recruited, and biopsies were obtained from the right atrial appendage during cannulation. Postoperative, all patients were rhythm-monitored until discharge and randomized to POAF (n=20) or sinus rhythm (n=43). The expression of the micro RNAs miR-199a and miR-195 was quantified by real-time PCR. SIRT1 protein was detected by western blot analysis. RESULTS: The relative expression of miR-199a in the POAF group was significantly decreased compared to the control group (0.77±0.27 vs. 1.11±0.69, P=.022) Accordingly, SIRT 1 protein was significantly induced in tissue probes of patients with POAF (P<.001). CONCLUSION: Altered expression of the SIRT1 protein regulating miR-199a in human atrial tissue was found to be related to the occurrence of POAF, indicating its usefulness as a biomarker for cardiac surgery management.

Etanercept protects myocutaneous flaps from ischaemia reperfusion injury: An experimental study in a rat tram flap model.

Background Being an inevitable component of free tissue transfer, ischemia-reperfusion injury tends to contribute to flap failure. TNF-α is an important proinflammatory cytokine and a prominent mediator of the ischemia-reperfusion injury. Etanercept, a soluble TNF-α binding protein, has shown anti-inflammatory and anti-apoptotic effects in animal models of renal and myocardial ischemia-reperfusion injury. We have designed an experimental study to investigate the effect of etanercept on myocutaneous ischemia-reperfusion injury on transverse rectus abdominis myocutaneous flap model in rats. Methods Twenty-four male Sprague-Dawley rats were divided into 3 groups: In group 1 (sham), the TRAM flap was raised and sutured back without further intervention. In group 2 (control), the flap was raised and the ischemia-reperfusion protocol was followed. In group 3, etanercept (10 mg/kg, i.v.) was administered 10 minutes before reperfusion. At the end of the reperfusion period, biochemical and histolopathological evaluations were performed on serum and tissue samples. Results In the etanercept group the IMA and 8-OHdG levels (p = 0.005 and p = 0.004, respectively) were found significantly lower, and the GSH and SOD levels (p = 0.01 and p < 0.001, respectively) significantly higher in comparison to the control group. The histopathological analysis has revealed a lower degree of hyalinization, degenerated muscle fibers and nuclear change in the etanercept group compared to the control group. Conclusion The results of our experimental study indicate that etanercept offers protection against ischemia-reperfusion injury in skeletal muscle tissue, enhancing the TRAM flap viability. The ability of etanercept to induce ischemic tolerance suggests that it may be applicable in free-flap surgery.

An easy and noninvasive technique for harvesting split thickness skin grafts in rats.

Skin graft studies in rats constitute a valuable adjunct to scientific human experimentations, however the harvesting of split thickness skin graft poses a challenge to the researcher due to the presence of panniculus carnosus tissue in rat skin. This striated muscle tissue renders significant laxity and mobility to the skin layer, greatly interfering with the process of skin graft harvest. In order to fixate the rat skin and limit its flexibility various techniques and modifications have been described, which mostly rely on the use of subdermal implanted templates. These methods are therefore time consuming, with an additional exposure to surgical stress and wounds. A new and simple technique is presented which offers a rapid and reliable alternative to the existing methods of split thickness skin graft harvesting without any additional invasive procedure or extra instruments other than the researchers hands and a dermatome.

Endovascular stent-graft excision and surgical aortic reconstruction.

Endovascular aneurysm repair is being used more often and replacing open surgical repair as the treatment option for aortic aneurysm. Early results are better than those of open surgical repair, but the need for a second intervention is greater. Excision of a previously placed stent-graft by different surgical methods is very difficult and has high mortality and morbidity rates. We describe 3 patients who had previous endovascular aneurysm repair and were treated by an open surgical method with near total excision, leaving part of the stent-graft in the native aortic tissue.

Tip-Oriented Closed Rhinoplasty Built on Septocolumellar Suture and a New Caudal Septal Graft Technique.

BACKGROUND: A beautiful and appealing nose receives the greatest contribution from the nasal tip subunit, which should be regarded as the primary center of attention during a rhinoplasty procedure. In achieving the desired shape and position of the nasal tip during closed rhinoplasty, the septocolumellar suture functions as the major determinant together with the caudal portion of the septal cartilage, which has a significant influence on the versatility of the septocolumellar suture. The purpose of this study was to present the analysis of the indications, the technical steps, and the advantages of caudal septal graft and septocolumellar suture utilization in closed rhinoplasty. METHODS: The septocolumellar suture with or without the caudal septal graft combination procedure has been performed in 2286 patients via a closed rhinoplasty approach. Intraoperatively, the septal cartilage at hand was thoroughly evaluated and one of the 5 types of caudal septal grafts was used when necessary. After the establishment of a strong and straight septal cartilage with sufficient height and length, 4 different septocolumellar sutures in a specific order were used to modify the relationship between the lower lateral cartilages and the nasal septum. RESULTS: Of the 2286 cases, 1837 (80.3%) were primary and 449 (19.7%) secondary rhinoplasties, which have been followed up for 9 to 48 months. The caudal septal graft was combined to the septocolumellar suture in 621 (27.1%) patients. Of the caudal septal grafts, 69.7% were used for primary rhinoplasty cases, and 30.3% for secondary rhinoplasties. At the 18th month postoperatively, tip projection was found to be satisfactory for 98% of the patients. CONCLUSIONS: The septocolumellar suture combined with caudal septal graft in closed rhinoplasty substantially facilitates the achievement of a cosmetically and functionally pleasing end result, bringing the solution for a wide array of problems such as short nose, supratip deformity, nasolabial angle change, or columellar bowing. Nevertheless, the technique has a steep learning curve; therefore, a meticulous preoperative evaluation should be exerted, a precise surgical planning should be prosecuted, and an excessive reduction of the nasal tip or exaggerated columellar retraction should be avoided.

Mitral valve regurgitation due to annular dilatation caused by a huge and floating left atrial myxoma.

We describe a case of mitral valve annular dilatation caused by a huge left atrial myxoma obstructing the mitral valve orifice. A 50-year-old man presenting with palpitation was found to have a huge left atrial myxoma protruding into the left ventricle during diastole, causing severe mitral regurgitation. The diagnosis was made with echocardiogram. Transoesophageal echocardiography revealed a solid mass of 75 × 55 mm. During operation, the myxoma was completely removed from its attachment in the atrium. We preferred to place a mechanical heart valve after an annuloplasty ring because of severely dilated mitral annulus and chordae elongation. The patient had an uneventful recovery. Our case suggests that immediate surgery, careful evaluation of mitral valve annulus preoperatively is recommended.

Comparison of bone prefabrication with vascularized periosteal flaps, hydroxyapatite, and bioactive glass in rats.

BACKGROUND: Periosteal flaps possess osteoprogenitor cells and an osteoinductive potential that can be further augmented by combination with a biodegradable scaffold; therefore, various osteoconductive and osteostimulative biomaterials are frequently combined with periosteal flaps in studies of bone prefabrication. An experimental study was designed to determine and compare the contribution of bioactive glass and hydroxyapatite to osteoneogenesis in rats when combined with a periosteal flap. MATERIALS AND METHODS: In 60 Sprague Dawley rats, saphenous artery periosto-fasciocutaneous island flaps were transposed to abdomen. In group 1, the flap was left alone, in group 2, an empty artificial pocket made of Gore-Tex (W. L. Gore & Associates, Inc.; Flagstaff, AZ) was sutured onto the periosteal layer, and in groups 3 and 4, the pocket was filled with bioactive glass and hydroxyapatite, respectively. Following sampling for histological analysis, a 4-point scoring system was used to grade inflammatory cell infiltration, osteogenesis, angiogenesis, and cell migration into the bioactive material. RESULTS: The combination of the periosteal flap with any of the bioactive materials resulted in significantly higher percentages of animals exhibiting osteogenesis (80% in hydroxyapatite group and 93.3% in the bioactive glass group; p = 0.0000528) and angiogenesis. Comparison of the bioactive material groups revealed that a significantly higher proportion of animals in the bioactive glass group exhibited moderate or severe inflammation (80 vs. 20%; p = 0.002814). CONCLUSION: Periosteal flaps prefabricated with hydroxyapatite or bioactive glass in rats exhibit osteogenic capacities that are not dependent on direct bone contact or proximity to vascular bony tissue. The innate capacity of the periosteal flap when utilized alone for osteoneogenesis was found to be rather insufficient.