Usage of rotational atherectomy and drug-coated balloon angioplasty for isolated popliteal artery lesions: two-year results of a retrospective study.

OBJECTIVES: In this study, perioperative properties and early and mid-term clinical outcomes of endovascular revascularization with a combined usage of rotational atherectomy (RA) and drug-coated balloon angioplasty (DCB) angioplasty for isolated popliteal artery lesion were reported. METHODS: A total of 28 patients with isolated popliteal artery stenosis who underwent combined RA and DCB angioplasty between December 2018 and September 2022 were analyzed retrospectively. Temren atherectomy system (Invamed, Ankara, Turkey) and Extender paclitaxel-coated drug-coated balloon catheter (Invamed, Ankara, Turkey) were used in all cases. The main outcome was primary patency; secondary outcomes were technical success, freedom from amputation, and mortality. RESULTS: The mean age of patients was 64.2 ± 9.1 years and the majority of the patients were male (n = 20; 71.4%). Types of the lesions were total occlusion in 24 limbs and critical stenosis in 4 limbs. The mean total occlusion length was 65.2 ± 14.2 mm. Flow-limiting dissection was seen in lesions of 2 patients (7.1%) and treated with prolonged balloon dilatation without bail-out stenting requirement. Technical success defined as an adequate vascular lumen (less than 30% stenosis) was achieved in 26 (92.8%) with a mean follow-up of 17.2 ± 8.2 months. The mean primary patency rates at 12 months and 24 months were 92.3% ± 3.2 and 81.2% ± 3.2, respectively. Complications included 1 distal embolization following RA, 2 flow-limiting dissections, and 3 puncture site hematomas. CONCLUSIONS: Endovascular procedures using combined RA and DCB angioplasty seem to be effective alternative treatment modalities for the treatment of popliteal artery lesions with high rates of primary patency and freedom from TLR.

Comparison of cyanoacrylate closure and radiofrequency ablation for the treatment of small saphenous veins.

BACKGROUND: The objective of this study was to compare the early and mid-term results of radiofrequency ablation and cyanoacrylate ablation used in the treatment of small saphenous insufficiency. METHODS: A total of 84 patients with isolated small saphenous vein insufficiency who underwent either cyanoacrylate ablation (CA) (Group 1, n = 40) or radiofrequency ablation (RFA) (Group 2, n = 44) were analyzed retrospectively. RESULTS: The occlusion rate of target vessel was 95% in Group 1 and 93.1% in Group 2 patients, respectively, at 1-year follow-up without any significant difference. Sural nerve injury was observed in 3 (6.8%) patients in Group 2 due to the thermal damage of the RFA device. CONCLUSIONS: While both techniques can be used with satisfactory and safe results in 1-year follow-up period, cyanoacrylate ablation may have a better safety profile compared to radiofrequency ablation due to lower complication rates in terms of paresthesia and sural nerve damage with similar occlusion rates.

Long-Term Endothelial Cell Viability After Deep Anterior Lamellar Versus Penetrating Keratoplasty for Keratoconus.

OBJECTIVES: We compared long-term endothelial cell survival after penetrating versus after deep anterior lamellar keratoplasty for keratoconus. MATERIALS AND METHODS: We retrospectively compared 64 eyes of 55 patients who had penetrating keratoplasty and 40 eyes of 37 patients who had deep anterior lamellar keratoplasty for keratoconus (October 2003-February 2021). Best-corrected visual acuity, Goldmann applanation tonometry, fundus examination with 90D lens, and specular microscopy with CEM-530 (Nidek) were performed preoperatively and every 6 months postoperatively. Main outcomes were endothelial cell density, central corneal thickness, and visual acuity. Secondary outcomes were coefficient of variation, hexagonality, graft rejection episodes, and graft clarity. RESULTS: We found no significant differences between the 2 treatment groups regarding patient age, donor age, preoperative vision, central corneal thickness, and recipient-donor trephine diameters. Mean follow-up was 92.5 months. In deep anterior lamellar keratoplasty, the endothelium was preserved significantly better for 10 years versus for penetrating keratoplasty. Mean endothelial density in penetrating versus deep anterior lamellar keratoplasty was 2006.7 versus 2354.7 cells/mm2 at 1 year (P = .010), 1170.5 versus 2048.2 at 5 years (P <.001), and 972.5 versus 1831.6 at 10 years (P < .001). Cumulative endothelial cell loss was 43% and 19.7% at 10 years for penetrating and anterior lamellar keratoplasty, respectively. Significantly more thickening of central cornea was shown in penetrating keratoplasty after 7 years. Corneal thickness was 583.0 µm in penetrating and 545.1 µm in deep anterior lamellar keratoplasty (P = .002) at 10 years. Vision gain and coefficient of variation were similar. Hexagonality decreased significantly in both groups at 10 years. Rates of rejection were 12.5% in penetrating and 7.5% in deep anterior lamellar keratoplasty. Graft survival rates were 97.5% and 96.9%, respectively. CONCLUSIONS: In keratoconus, endothelial vitality is better preserved with deep anterior lamellar keratoplasty than with penetrating keratoplasty over a 10-year follow-up.

The Effect of Balloon-Assisted Pharmacomechanical Catheter-Directed Thrombolysis on the Patency and Post-Thrombotic Syndrome in Patients with Acute Iliofemoral Deep Vein Thrombosis: Is it Really Necessary or Not?

BACKGROUND: The objective of this study was to describe the contribution and advantage of balloon-dilatation of iliac and femoral veins following pharmacomechanical catheter-directed thrombolysis (PCDT) on the development of post-thrombotic syndrome (PTS). METHODS: From October 2018 and January 2022, 85 patients with acute total occlusion of the iliac and femoral veins were treated with PCDT. The cohort was divided into 2 groups depending on the utilization of concomitant balloon dilatation of iliac and femoral veins (Group 1, n = 34, 40.0%) or not (Group 2, n = 51, 60.0%) during the PCDT. All patients underwent duplex ultrasound scanning for evaluating the patency of iliac veins and recanalization rates at 3, 6, and 12 months postoperatively. The Villalta score was used to score the severity of PTS at 12 months postoperatively. RESULTS: Patients who underwent balloon-assisted PCDT (group 1) exhibited significantly higher primary patency rates in common iliac vein (CIV) (recanalization 84.3 ± 14.6%, P = 0.003), external iliac vein (EIV) (recanalization 82.8 ± 17.2, P = 0.003) and common femoral vein (CFV) (recanalization 88.1 ± 12.1%, P = 0.038) compared with the group 2 at the end of 12 months follow-up. Only 2 patients underwent venous stenting in follow-up due to severe venous claudication, however, 13 patients were required iliac vein stenting due to severe PTS proved with a high Villalta score at 12-month follow-up. The d-dimer level at 1-year follow-up had also significantly lower in Group 1 due to higher rates of patency and lower thrombosis burden. The most common bleeding events were hematuria (n = 4) or oozing in the puncture site (n = 4). CONCLUSIONS: This study showed that balloon-assisted PCDT reduces the risk of PTS, is more successful in common iliac vein recanalization, reduces the need for the venous stent, and even lowers the D-dimer levels of the patients compared to routine PCDT alone.

Non-Arteritic Anterior Ischaemic Optic Neuropathy with Progressive Macular Ganglion Cell Atrophy due to COVID-19.

A 72-year-old man with type II diabetes mellitus presented with sudden painless vision loss and an inferior visual field defect in his right eye. He had previously tested positive for COVID-19 disease with the symptoms starting 13 days before the onset of vision loss. His decimal visual acuity, 55 days after the onset of visual symptoms, was 0.3 and this decreased over the following week to counting fingers. 24-2 visual field analysis revealed an inferior altitudinal defect. Dilated fundus examination revealed mild optic disc swelling in the right eye. The left eye was normal. He was diagnosed with non-artertic anterior ischaemic optic neuropathy (NAION). On spectral domain optical coherence tomography there was retinal thinning in the supero-temporal foveal area. Macular ganglion cell layer - inner plexiform retinal layer complex analysis showed progressive atrophy that developed from the supero-temporal to the infero-nasal fovea. COVID-19 infection may lead to NAION.

Removal of Hydroxychloroquine Using Engineered Biochar from Algal Biodiesel Industry Waste: Characterization and Design of Experiment (DoE).

Adsorption of hydroxychloroquine (HCQ) onto H3PO4-activated Cystoseira barbata (Stackhouse) C. Agardh (derived from algal biodiesel industry waste) biochar was investigated via batch experiments and mathematical models. The activated biochar (BC-H) was produced in a single step by using the microwave irradiation method. Thus, it was obtained with a low cost, energy efficiency and by promoting clean production processes. BC-H exhibited a remarkable adsorption efficiency (98.9%) and large surface area (1088.806 m2 g-1) for removal of HCQ. The Langmuir isotherm and the pseudo-second-order kinetic models were the best fit for the equilibrium adsorption and kinetics experiments, and the maximum monolayer adsorption capacity (qmax) was found to be 353.58 µg g-1. Additionally, the experiments with real wastewater showed that BC-H's ability to adsorb HCQ was not affected by competitive ions in the water. The Taguchi orthogonal array (L16 OA) experimental design was applied for the effective cost optimization analyses of the adsorption process by considering four levels and four controllable factors (initial pH, HCQ concentration, amount of adsorbent and contact time). Scanning electron microscopy, Fourier transform infrared spectroscopy and Brunauer-Emmett-Teller analyses were used for characterizing the adsorbent. The findings showed that BC-H can be used as an effective and low-cost adsorbent in the removal of HCQ from water. Supplementary Information: The online version contains supplementary material available at 10.1007/s13369-021-06235-w.

Pre-operative predictors of lower extremity swelling following total knee arthroplasty in patients with venous insufficiency and osteoarthritis.

PURPOSE: Post-operative swelling and oedema following total knee arthroplasty (TKA) are one of the most important causes of dissatisfaction. We aimed to assess the clinical variables associated with post-operative swelling and edema after TKA and to compare their performance in respect of predicting them pre-operatively. METHODS: The study cohort comprised 116 patients who underwent TKA between January 2018 and May 2019 in our centre. The diameters and the grade of venous insufficiency (VI) in the lower extremity veins were measured with duplex ultrasonography preoperatively and at one and three months post-operatively. The study cohort was divided into the patients with leg swelling positive with a difference in leg circumference of > 2 cm (n = 56, 48.2%) and leg swelling negative with a difference of ≤ 2 cm (n = 60, 51.7%) from the pre-operative leg diameter. RESULTS: Independent predictors for lower extremity swelling were pre-operative great saphenous diameter (GSV) diameter > 5.5 mm [odds ratio (OR) 2.51, 95% CI 0.24-0.91; p = 0.0012], GSV reflux > 1 s [OR 3.28, 95% CI 1.16-12.1; p = 0.003], deep only VI [OR 1.32, 95% CI 0.74-1.87; p = 0.021], CEAP C4-6 [OR 1.62, 95% CI 0.36-0.91; p = 0.018], and hypothyroidism [OR 1.55, 95% CI 1.31-11.2; p = 0.031]. CONCLUSION: GSV diameter of > 5.38 mm and GSV reflux duration > 1.23 s had the best predictive value for lower extremity oedema following TKA.

Patency Rates After Successful Arteriovenous Fistula Thrombectomy: Relevance of the Flow/d-Dimer Ratio in the Decision-Making.

OBJECTIVES: Surgical thrombectomy for acute arteriovenous fistula (AVF) thrombosis is one of the primary salvage intervention. The independent risk factors affecting the patency of AVF after a successful thrombectomy are yet unknown. Here, the author aimed to report the results of surgically corrected AVFs and the independent risk factors which may cause early failure following the surgical salvage. METHODS: The study cohort comprised 24 patients who had acute AVF thrombosis and underwent successful surgical thrombectomy in the first 24 to 48 hours between January 2016 and April 2020 in our center. The study group was divided into patients with recurrent AVF thrombosis (n = 11, 45.8%) and without recurrent AVF thrombosis (n = 13, 54.1%) following surgical thrombectomy with a follow-up of 22.4 ± 6.8 months. Postthrombectomy primary and secondary patency of AVF were also evaluated. RESULTS: The mean age of the cohort was 58.1 ± 15.2 years. A simple thrombectomy was performed for all cases. Only 2 cases have required a revision at the anastomosis due to severe intimal hyperplasia. Postthrombectomy primary patency rate was 45.5% for 18 months. Receiver operating characteristic analysis was performed with a resulting area under the curve value of 0.81 (95% CI: 0.35-0.94, P = .006) for flow (mL)/d-dimer (ng/mL) <0.63 in predicting recurrent AVF thrombosis following surgical thrombectomy. CONCLUSIONS: Flow (mL)/d-dimer (ng/mL) <0.63 was independent predictor of recurrent thrombosis (RT) of a surgically salvaged AVF. The patients at risk for RT or who may benefit from further intervention should be identified with predictive parameters.

Multiple Valve Implantation Through a Minimally Invasive Approach: Comparison of Standard Median Sternotomy and Right Anterior Thoracotomy.

BACKGROUND: Following developments in the area of minimally invasive surgery and good, recently published surgical results, the areas in which minimally invasive surgery can be used are beginning to expand. This study aimed to describe experience and show the feasibility and safety of minimally invasive multiple valve implantation with right anterior minithoracotomy (RAT) and compare the outcomes with cases that underwent multiple valve surgery via a standard median sternotomy. METHODS: The study cohort comprised 52 patients with combined valvular disease who underwent aortic valve replacement and mitral valve replacement or repair, and/or tricuspid valve ring annuloplasty through median sternotomy (control group n=32) or minimally invasive surgery through a RAT (study group n=20) between January 2012 and December 2018 at the current centre. Preoperative evaluation included coronary catheterisation and multisliced computerised tomography in all patients. Postoperative clinical outcomes and haemodynamic performance of heart valves were reviewed. RESULTS: The mean age of patients was 72.6±7.1 years, and 50% were male. Seventeen (17) patients (32.6%) were in New York Heart Association functional class III or IV. Three (3) patients (7.6%) had third-degree atrioventricular block requiring permanent pacemaker implantation. Mean follow-up was 21±3.9 months (maximum 26 months). No major paravalvular leakage occurred, and there was no postoperative valve migration in either group. Non-valve-related deaths occurred in five patients during follow-up. CONCLUSION: This study showed that minimally invasive multiple valve implantation is a technically feasible and safe procedure with acceptable surgical outcomes and similar postoperative quality when compared with median sternotomy.

Effects of hemodialysis access type on right heart geometry in adolescents.

INTRODUCTION: This study aimed to investigate the complication frequency and the changes in right heart geometry with different access types in the pediatric population. METHODS: We included 32 consecutive patients aged between 10 and 19 and who underwent hemodialysis sessions via permanent hemodialysis catheter (nHC = 18) or arterio-venous fistula (nAVF = 14) between January 2013 and March 2018. We recorded and compared the complication frequency and the changes in echocardiography findings with different access types. FINDINGS: Demographic data were similar in both groups. Number of new access creation (nHC = 15 vs nAVF = 1) and all complications (nHC = 19 vs nAVF = 6) were significantly higher in hemodialysis catheter group and the statistical analysis showed the superiority of arterio-venous fistula group in comparison of event-free survival (event-free patients; nAVF = 8 (57%), nHC = 3 (16%); p = 0.02). Control echocardiography showed impressive delta-change in right atrium diameter (p = 0.04), right ventricular end-diastolic volume (p = 0.004), right ventricular end-systolic volume (p < 0.001), and right ventricular free wall thickness (p = 0.009) in arterio-venous fistula group, but no significant difference between two groups in terms of delta-change of right ventricular ejection fraction (p = 0.35), fractional area change (p = 0.21), and tricuspid annular plane systolic excursion (p = 0.13) parameters. CONCLUSION: Arterio-venous fistula has lower risk of complications, but overloading stress on right heart chambers triggers remodeling process and geometrical changes, which can be early pieces of evidence of delayed right heart dysfunction in pediatric hemodialysis patients.

Modeling heavy metal removal by retention on Laurus nobilis leaves biomass: linear and nonlinear isotherms and design.

Heavy metal industries pose a serious threat to the environment. Conventional methods used for heavy metal removal are generally not always low-cost and environmentally friendly. So, researchers focused to investigate alternative biosorbents for the uptake of heavy metal. In this study, Laurus nobilis leaves (LNL) were used as a biosorbent for the uptake of toxic metals such as Pb2+ and Cd2+ from aqueous solutions. Batch biosorption experiments under varied conditions, such as biosorbent dosage, solution pH, heavy metal concentration, biosorption time, ionic strength, humic acid effect and competitive metal ions (Cd(II), Pb(II), Cu(II) and Zn(II)) were performed. The biomass was characterized using FT-IR spectra and SEM images. The nonlinearized and linearized isotherm models were compared and discussed. A single-stage batch bioreactor system for each heavy metal based on the best fit nonlinear isotherm model also has been presented. The biosorption of Pb(II) on LNL fitted better in the Langmuir model and Cd(II) biosorption fitted better in the Freundlich model by nonlinearized equations. The LNL exhibited the maximum monolayer biosorption capacities (qmax) of 7.1 and 32.5 mg/g for cadmium and lead, respectively. LNL showed great potential especially in Pb(II) uptake. LNL may be promising for heavy metal removal from aqueous environment.

Right Ventricular Strain to Assess Early Right Heart Failure in the Left Ventricular Assist Device Candidate.

PURPOSE OF REVIEW: Right heart failure (RHF) following left ventricular assist device implantation (LVAD) remains the primary cause of postoperative mortality and morbidity, and prediction of RHF is the main interest of the transplantation community. In this review, we outline the role and impact of right ventricular strain in the evaluation of the right ventricle function before LVAD implantation. RECENT FINDINGS: Accumulating data suggest that measurement of right ventricular longitudinal strain (RVLS) has a critical role in predicting RHF preoperatively and may improve morbidity and mortality following LVAD implantation. However, the significant intraobserver, interobserver variability, the lack of multicenter, prospective studies, and the need for a learning curve remain the most critical limitations in the clinical practice at present. This review highlighted the importance of right ventricular strain in the diagnosis of RHF preoperatively and revealed that RVLS might have a crucial clinical measurement for the selection and management of LVAD patients in the future with the more extensive multicenter studies.

Effect of temporary vascular shunting as a previous intervention on lower extremity arterial injury: Single center experiences in the Syrian Civil War.

BACKGROUND: The goal of this retrospective study was to clarify the effect of using temporary vascular shunt (TVS) as a previous intervention. METHODS: A total of 96 cases with war-related lower extremity arterial injury and surgically treated between October 2013 and March 2016 were included in the study. The patients were divided into two groups: those in which TVS was performed as a previous intervention on admission (TVS group, n=24) and those in which compression, tourniquet, and ligation/clampage were performed as a previous intervention on admission (non-TVS group, n=72). RESULTS: In comparing injury pattern, there was no difference between the two groups. In addition, mean hematocrit level, mean systolic blood pressure, the incidence of concomitant vein injury, nerve injury, soft tissue damage, and bone injury were similar in both groups. The overall amputation rate was 19%. There were a total of 18 amputations, with 1 (4%) in the TVS group and 17 (24%) in the non-TVS group. The difference on amputation rate was statistically significant. The mean values of the mangled extremity severity score (MESS) were 6.45 in the TVS group and 7.44 in the non-TVS group. The overall mean MESS was 7.1. The duration of ischemia (DoI) was 4.84+-1.84 h in the TVS group and 5.95+-1.92 h in the non-TVS group. These differences in MESS and DoI were statistically significant. CONCLUSION: We think that it may be beneficial for patients to consider a TVS to reduce DoI and gain time for surgical revascularization. As a result, the present study demonstrates that the use of TVS may successfully serve as a bridge between initial injury and definitive repair with a reduction in amputation rates.

Surgical repair of non-obstructive supracardiac total anomalous pulmonary venous connection in an adult patient.

Total anomalous pulmonary venous connection is an uncommon congenital heart malformation with abnormal drainage of all pulmonary veins into the systemic venous system. Despite its very low incidence, it is usually a pediatric cardiac emergency and rarely allows survival into adulthood without surgical correction in infancy. Herein, we report one of the oldest cases from Turkey who was successfully operated for non-obstructive, supracardiac total anomalous pulmonary venous connection.

Sutureless Valve Replacement Through a Right Anterior Mini-thoracotomy in Elderly Patients With Stenotic Bicuspid Aortic Valve.

Several indications for sutureless aortic valve replacement (SU-AVR) have been a matter of debate. We evaluated our experience with Perceval-S (LivaNova group, Saluggia, Italy) SU-AVR in patients with severe aortic stenosis (AS) involving bicuspid aortic valve (BAV), even though presence of BAV is still considered to be a contraindication for sutureless valves. From January 2013 through March 2018, 13 patients with severe AS involving BAV underwent SU-AVR with the Perceval-S (LivaNova group, Saluggia, Italy) prosthesis in a single center. Preoperative evaluation included coronary catheterization and multisliced computerized tomography was performed in all patients. Three-dimensional transthoracic echocardiography was used to evaluate for obtaining the anatomy and phenotype of BAV. Minimally invasive approach through right anterior thoracotomy from third intercostal space was performed for all patients. The mean age was 72.8 ± 2.26 years ranging from 70 to 77, and 53.8% (n = 7) were male. The mean aortic valve gradient decreased from 46.4 ± 13.8 to 13.6 ± 4.4 mmHg postoperatively. The mean aortic valve area increased from 0.69 ± 0.22 to 1.81 ± 0.38 cm2. There was no in-hospital mortality. One patient (7.6%) had third-degree atrioventricular block requiring permanent pacemaker implantation. Mean follow-up was 15.1 ± 6.3 months (maximum 2 years). No major paravalvular leakage or valve migration occurred postoperatively. This study shows that SU-AVR is a technically feasible and safe procedure in patients with severe AS and BAV with acceptable good surgical outcomes. Presence of BAV in AS should not be considered a contraindication to Perceval-S prosthesis (LivaNova group, Saluggia, Italy).

Right ventricular free wall longitudinal strain and stroke work index for predicting right heart failure after left ventricular assist device therapy.

OBJECTIVES: Right heart failure (RHF) is an important prognostic factor in continuous-flow left ventricular assist device (LVAD) therapy. We aimed to assess the clinical variables associated with RHF after LVAD implantation and to compare their performance against currently available RHF predictive scoring systems. METHODS: The study cohort comprised 57 patients who underwent LVAD therapy between January 2012 and May 2018 in our centre. The mean age of the patients was 39.9 ± 18.3 years, and 43 (81.1%) of them were men. Thirty-eight patients (66.6%) were in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile I or II. The study cohort was divided into the patients with RHF postoperatively (n = 20, 35.1%) and without RHF (n = 37, 64.9%). RESULTS: Independent predictors for RHF were preoperative right ventricular ejection fraction <25% [odds ratio (OR) 4.68, 95% confidence interval (CI) 1.41-15.5; P = 0.01], right ventricular stroke work index <400 mmHg ml-1 (OR 3.73, 95% CI 1.01-13.7; P = 0.04), right ventricular outflow tract systolic excursion <7 mm (OR 1.55, 95% CI 0.31-0.84; P = 0.002), right ventricular outflow tract fractional shortening <15% (OR 1.62, 95% CI 0.34-0.78; P = 0.02), right ventricular free wall longitudinal strain ≤19% (OR 3.13, 95% CI 1.01-2.43; P = 0.003), right ventricular fractional area change <27% (OR 3.71, 95% CI 1.15-11.9; P = 0.02) and prealbumin <14 mg/dl (OR 3.45, 95% CI 1.07-11.03; P = 0.03). Modest diagnostic performance for RHF was detected in 4 of 7 validated scoring systems with resulting area under the curve values of 0.70 (95% CI 0.55-0.84; P = 0.001) for the Seattle Heart Failure Model; 0.68 (95% CI 0.49-0.81, P = 0.03) for the Fitzpatrick's; 0.68 (95% CI 0.53-0.83, P = 0.028) for the acute physiology and chronic health evaluation (APACHE) II; and 0.66 (95% CI 0.50-0.82, P = 0.04) for the model for end-stage liver disease scoring systems. However, we found best discrimination performance of the score with a resulting area under the curve value of 0.94 (95% CI 0.55-0.89, P = 0.03) for right ventricular free wall longitudinal strain ≥-15.5% and 0.82 for right ventricular stroke work index <400 mmHg ml-1 m-2 in predicting RHF. CONCLUSIONS: Right ventricular free wall longitudinal strain ≥-15.5% and right ventricular stroke work index <400 mmHg ml-1 m-2 were independent predictors of RHF following LVAD implantation. Currently available prediction risk scores had the modest power of accuracy in the low INTERMACS profile Turkish population.

Comparison of minimally invasive cardiac surgery incisions: Periareolar approach in female patients.

OBJECTIVE: All innovations in cardiac surgery provide us with new techniques to perform surgery through smaller incisions with less invasive and best cosmetic results. After promising results in minimally invasive cardiac surgery (MICS), pain and cosmetic appearance became important end points, especially for female patients. In the current study, we intended to evaluate the surgical results and cosmetic satisfaction with the periareolar and submammary incision types in cardiac surgery. METHODS: Ninety-four female patients underwent MICS between July 2013 and March 2018. MICS was performed in 62 patients via periareolar incision and in 32 patients via submammarian incision. We investigated the incision size, wound infection, pain levels by using a postoperative standard pain-level questionnaire, the postoperative scar size, and patient satisfaction using a postoperative patient questionnaire. RESULTS: Periareolar incision size was smaller than the submammary incision (Group A: 5.6±0.6 vs. Group B: 6.7±0.8, p=0.001). Four patients from Group B had superficial wound infection (p=0.01). Patients who underwent MICS via periareolar incision and submammary incision had similar pain level (p=0.2). The scar tissue was smaller in size and postoperatively healed better in the following days for the patients with periareolar incision due to the elastic structure of breast tissue. (Group A: 4.3±0.4 vs. Group B: 5.3±0.2, p=0.001). CONCLUSION: Our study suggests that the periareolar approach would be more aesthetic, show better healing, and have a smaller scar size in female patients.

Promising utilization areas of therapeutic plasmapheresis in cardiovascular surgery practice.

OBJECTIVE: Apheresis is performed for treatment of numerous diseases by removing auto-antibodies, antigen-antibody complexes, allo-antibodies, paraproteins, non-Ig proteins, toxins, exogenous poisons. In current study, we present our experience of using therapeutic plasma exchange (TPE) in patients with different types of clinical scenarios. METHODS: Between January 2013 and May 2016, we retrospectively presented the results of 64 patients in whom postoperative TPE was performed in ICU setting after cardiac surgery. Patients were grouped into four as; 1-sepsis (n = 26), 2-hepatorenal syndrome(n = 24), 3-antibody mediated rejection(AMR) following heart transplantation(n = 4) and 4-right heart failure(RHF) after left ventricular asist device(LVAD)(n = 10). Hemodynamic parameters were monitored constantly, pre- and post-procedure peripheral blood tests including renal and liver functions and daily complete blood count (CBC), sedimentation, C-reactive protein and procalcitonin (ng/ml) levels were studied. RESULTS: The mean age was 61 ± 17.67 years old and 56.25% (n = 36) were male. Mean Pre TPE left ventricular ejection fraction (LVEF) (%), central venous pressure (CVP)(mmHg) pulmonary capillary wedge pressure (PCWP)(mmHg) and pulmonary arterial pressure (PAP)(mmHg) were measured as 41.8 ± 8.1, 15.5 ± 4.4, 17.3 ± 3.24 and 39.9 ± 5.4, respectively. Procalcitonin (ng/ml) level of patients undergoing TPE due to sepsis was significantly reduced from 873 ± 401 ng/ml to 248 ± 132 ng/ml. Seventeen (26.5%) patients died in hospital during treatment, mean length of intensive care unit (ICU) stay(days) was 13.2 ± 5.1. CONCLUSION: This study shows that TEP is a safe and feasible treatment modality in patients with different types of complications after cardiac surgery and hopefully this study will lead to new utilization areas.

Sutureless aortic valve replacement with concomitant valvular surgery.

OBJECTIVES: Sutureless aortic valve replacement (SU-AVR) is an alternative technique to standard aortic valve replacement. We evaluated our experience with the Perceval SU-AVR with concomitant mitral valve surgery, with or without tricuspid valve surgery, and aimed to discuss the technical considerations. METHODS: From January 2013 through June 2016, 30 patients with concomitant severe mitral valve disease, with or without tricuspid valve disease, underwent SU-AVR with the Perceval prosthesis in a single center. RESULTS: The mean age was 73.0 ± 6.6 years, ranging from 63 to 86 years, and 60% (n = 18) were male. Mean logistic EuroScore of the study cohort was 9.8 ± 4.6. Concomitant procedures consisted of mitral valve repair (n = 8, 26.6%), mitral valve replacement (n = 22, 73.3%), tricuspid valve repair (n = 18, 60%), tricuspid valve replacement (n = 2, 6.6%), and cryoablation for atrial fibrillation (n = 21, 70%). Median prosthesis size was 25 mm (large size). At 1 year, there were 2 deaths from noncardiac causes. One patient (3.3%) had third-degree atrioventricular block requiring permanent pacemaker implantation. Three patients (10%) had intraoperative supra-annular malpositioning of the aortic prosthesis, which was safely removed and reimplanted in all cases. Mean follow-up was 18 ± 4.5 for months (maximum 3 years). During the postoperative period, sinus rhythm restoration rate in patients who underwent the cryo-maze procedure was 76.1% (n = 16) at discharge. There was no structural valve deterioration or migration of the prosthesis at follow-up. CONCLUSIONS: Perceval SU-AVR is a technically feasible and safe procedure in patients with severe aortic stenosis with good results even in the presence of multivalvular disease and atrial fibrillation surgery.