Minimally invasive versus conventional mitral valve surgery: A propensity score matching analysis.

Background: This study aimed to compare the outcomes of minimally invasive mitral valve surgery and conventional surgery in terms of mortality and postoperative complications. Methods: A retrospective analysis was conducted on consecutive minimally invasive and conventional mitral valve surgeries performed between January 2019 and December 2022. Patients undergoing concomitant procedures were excluded from the study, and 293 patients (149 females, 144 males; mean age: 53.8±12.9 years; range, 18 to 82 years) were included in the study. Of these patients, 96 underwent minimally invasive surgery (MI group), and 197 underwent mitral valve surgery via conventional sternotomy (CS group). Propensity score matching was utilized to minimize the biases and confounding factors. After propensity score matching, 55 patients were included in each group. Results: There was no statistically significant difference in terms of mortality between the propensity score-matched groups (p=0.315), and no statistically significant difference in postoperative complications was observed between the groups. However, it was found that postoperative new-onset atrial fibrillation was lower in the minimally invasive group (p=0.022). Conclusion: This study demonstrates that minimally invasive mitral valve surgery is a safe alternative with similar mortality and postoperative complication rates compared to conventional surgery. Additionally, the study suggests an association between minimally invasive surgery and postoperative new onset atrial fibrillation.

Obesity Does Not Affect Major Outcomes in Robotic Coronary Surgery.

BACKGROUND: Robotic-assisted coronary surgery is gaining attraction as an alternative to traditional open-heart procedures, offering potential benefits such as decreased mortality rates, shorter hospital stays, and reduced complications. This study aimed to investigate the outcomes of robotic-assisted coronary surgery, focusing particularly on the impact of obesity. METHODS: A total of 210 consecutive patients underwent robotic-assisted coronary surgery over an eight-year period at a single institution. Patients were categorized based on body mass index (BMI), distinguishing between obese (BMI ≥30 kg/m2) and non-obese (BMI <30 kg/m2) groups. The analysis encompassed preoperative characteristics, operative factors, and postoperative outcomes. RESULTS: Comparisons between obese and non-obese patients revealed similar preoperative comorbidities. However, the operation time was prolonged in the obese group (p = 0.03). Major cardiac and cerebrovascular events, along with overall complications, displayed no significant disparities between the groups. Notably, superficial wound infections were more prevalent among obese patients (p = 0.03). Importantly, intensive care unit and hospital stay times were comparable between the two groups. CONCLUSION: Robotic-assisted coronary surgery demonstrates its potential as a viable alternative to conventional open-heart procedures, offering benefits such as reduced mortality rates, shorter hospital stays, and minimized perioperative complications. This study's findings underscore the feasibility and safety of this approach, with outcomes comparable between obese and non-obese patients.

Impact of Indexed Effective Orifice Area on the Quality of Life of Patients after Aortic Valve Replacement.

BACKGROUND: Improving health related quality of life is an important goal of aortic valve replacement. Inadequate effective orifice area of prosthesis according to the patient's body surface area may be associated with poor outcomes. In this study, we aimed to analyze impact of indexed effective orifice area (iEOA) on patients' quality of life after aortic valve replacement. METHODS: A total of 138 patients who underwent isolated aortic valve replacement were included to the study. Quality of life assessment was performed with EuroQol Group EQ-5D-5L questionnaire. Patients were divided into three groups based on iEOA (Group 1 had an iEOA of <0.65 cm2/m2 (19 patients), Group 2 had an iEOA between 0.65-0.85 cm2/m2 (71 patients), and Group 3 had an iEOA of >0.85 cm2/m2). Mean EQ-5D-5L scores were compared among the groups statistically. RESULTS: Mean EQ-5D-5L scores were lower in Group 1 than in Groups 2 and 3 (Group 1: 0.72 ± 0.18, Group 2: 0.83 ± 0.20, and Group 3: 0.86 ± 0.9, p = 0.044 and p = 0.014). The EQ-5D-5L score was significantly lower in patients with a ≥20 mmHg transvalvular gradient than those with a <20 mmHg (0.74 ± 0.25 vs. 0.84 ± 0.18, p = 0.014). CONCLUSIONS: Our results show that an iEOA <0.65 cm2/m2 is significantly associated with impaired postoperative health-related quality of life. Newer generation prostheses, transcatheter valve implantation, and root enlargement techniques should be kept in mind in preoperative planning.

Prognostic values of the C-reactive protein to albumin ratio and prognostic nutritional index in carotid endarterectomy patients.

OBJECTIVES: C-reactive protein to albumin ratio (CAR) and prognostic nutritional index (PNI) are novel parameters with proven prognostic importance in the postoperative outcomes of coronary and peripheral vascular diseases. In this study, we aimed to evaluate the ability of CAR and PNI to predict major cardiac and cerebrovascular events (MACCE) during the postoperative period of Carotid artery endarterectomy (CEA). METHODS: A total of 505 carotid endarterectomy patients were retrospectively evaluated. Of 505 patients, 23 patients who died and who experienced myocardial infarction or major neurologic complication in the first 30 days after the operation were included in MACCE group (Group 1). The remaining 482 patients were included in Group 2. Receiver operating characteristics (ROC) curve analysis was used to evaluate preoperative serum albumin value, lymphocytes count, PNI, and CAR to predict the MACCE. The DeLong test was used to compare the area below the curve (AUC) with each of these parameters. RESULTS: CAR (2.48 ± 1.82 and 1.64 ± 1.37) and CRP (9.98 ± 7.42 and 6.81 ± 5.70) values are statistically higher in Group 1 than in Group 2. PNI (41.59 ± 3.11 and 43.54 ± 4.20) and albumin (40.43 ± 3.15 and 42.35 ± 4.15) values were significantly lower in Group 1 than in Group 2. The accuracy of albumin (AUC: 0.669) in the prediction of MACCE was found to be the highest among CAR (AUC: 0.631), PNI (AUC:0.667), and CRP (AUC:0.631). CONCLUSION: Preoperative nutritional and inflammatory status is significantly associated with post-operative outcomes. PNI and CAR can be used for preoperative evaluation, as CEA is recommended for patients who have low possibility of having postoperative major adverse events.

The Effect of Hemodynamic Parameters on Cerebral Oxygenization During Carotid Endarterectomy

Abstract Objective/Introduction: Near-infrared spectroscopy (NIRS) is a non-invasive technique to detect cerebral ischemia by monitoring changes in regional cerebral oxygenation (rSO2) in the frontal lobes. However, there are no studies showing the changes in NIRS values in response to hemodynamic variations during stages of carotid endarterectomy (CEA) procedure and clinical implications of these changes. The aim of this study was to determine if hemodynamic changes affect NIRS values during carotid endarterectomy and if our results may help to provide strategies for hemodynamic management in these patients. Methods: A total of 50 consecutive patients undergoing CEA were prospectively included in the study. NIRS was measured at first minute after clamping of carotid artery, and then systolic blood pressure was increased above 150 mmHg. NIRS values from both hemispheres were recorded simultaneously at certain time points and were analyzed to evaluate the changes at different stages of operation and to assess correlations with hemodynamic parameters. Results: NIRS values on the right and left sides were correlated with systolic (right P<0.001, R2:0.24; left P=0.02, R2:0.10) diastolic (right P<0.001, R2:0.36; left P=0.001, R2:0.18) and mean (right P<0.001, R2:0.33; left P=0.003, R2:0.17) blood pressures when the patient was under general anaesthesia. NIRS values were significantly lower than pre-incision values just after clamping of carotid artery in both hemispheres (P=0.005 for the right and P<0.001 for the left side). Conclusion: NIRS values measured in our study show that there is a correlation between hemodynamic changes and cerebral oxygenation. This effect is especially pronounced while the patient is asleep and intubated, which implies the importance of close monitoring of patients with carotid disease during any surgery requiring general anaesthesia.

The Effect of Hemodynamic Parameters on Cerebral Oxygenization During Carotid Endarterectomy.

OBJECTIVE/INTRODUCTION: Near-infrared spectroscopy (NIRS) is a non-invasive technique to detect cerebral ischemia by monitoring changes in regional cerebral oxygenation (rSO2) in the frontal lobes. However, there are no studies showing the changes in NIRS values in response to hemodynamic variations during stages of carotid endarterectomy (CEA) procedure and clinical implications of these changes. The aim of this study was to determine if hemodynamic changes affect NIRS values during carotid endarterectomy and if our results may help to provide strategies for hemodynamic management in these patients. METHODS: A total of 50 consecutive patients undergoing CEA were prospectively included in the study. NIRS was measured at first minute after clamping of carotid artery, and then systolic blood pressure was increased above 150 mmHg. NIRS values from both hemispheres were recorded simultaneously at certain time points and were analyzed to evaluate the changes at different stages of operation and to assess correlations with hemodynamic parameters. RESULTS: NIRS values on the right and left sides were correlated with systolic (right P<0.001, R2:0.24; left P=0.02, R2:0.10) diastolic (right P<0.001, R2:0.36; left P=0.001, R2:0.18) and mean (right P<0.001, R2:0.33; left P=0.003, R2:0.17) blood pressures when the patient was under general anaesthesia. NIRS values were significantly lower than pre-incision values just after clamping of carotid artery in both hemispheres (P=0.005 for the right and P<0.001 for the left side). CONCLUSION: NIRS values measured in our study show that there is a correlation between hemodynamic changes and cerebral oxygenation. This effect is especially pronounced while the patient is asleep and intubated, which implies the importance of close monitoring of patients with carotid disease during any surgery requiring general anaesthesia.

Is Biochemical Follow Up Possible in Peripheral Arterial Disease Treatment: Hypoxia Inducible Factor-1 Alpha?

PURPOSE: The hypoxia inducible factor (HIF)-1 is a dimeric protein complex that plays an integral role in the body's response to hypoxia. This study aimed to analyze the regulation of HIF-1α following vascular and/or endovascular surgery in peripheral arterial disease (PAD) patients. MATERIALS AND METHODS: A total of 40 patients with PAD (≥Rutherford category 3) were included in this prospective study. The mean age was 61.9±9.2 years. Open surgery was performed in 16 patients, and endovascular intervention was performed in 34 patients. At preoperative (T1), postoperative day 1 (T2), and month 3 (T3), the serum HIF-1α levels were checked using the ELISA technique. RESULTS: At T3, the ankle-brachial index was significantly higher than the preoperative value (P<0.001). Serum HIF-1α levels at T1, T2, and T3 were 2.0±1.7 ng/mL, 1.9±1.7 ng/mL, and 1.6±1.4 ng/mL, respectively. Serum HIF-1α levels between T1 and T3 and between T2 and T3 were significantly different (P<0.05). The preoperative HIF-1α levels were lowest in iliac lesions compared to femoropopliteal or tibial lesions. CONCLUSION: The HIF-1α levels were decreased in all patients on postoperative days, T2 and T3, compared with the preoperative values. Our results indicated that HIF-1α may be a surrogate marker after revascularization in patients with PAD. Further studies are needed to analyze the sensitivity, specificity, and cut-off values of HIF-1α in patients with PAD.

Endovascular Treatment of Acute Aortic Occlusion with Critical Limb Ischemia using an AngioJet Device.

BACKGROUND: Acute aortic occlusion is an uncommon vascular emergency. REPORT: We report an endovascular procedure in a patient with acute aortic occlusion causing critical limb ischemia. Following thrombus debulking with AngioJet system, aortoiliac patency was achieved with bilateral iliac artery stent placement creating new aortic bifurcation. CONCLUSIONS: Pharmacomechanical thrombectomy may provide effective debulking of thrombus. It may be utilized before stenting, and may also be curative in selected cases.

Electron Microscopic Comparison of Radial Artery Grafts in Non-Diabetic and Diabetic Coronary Bypass Patients.

OBJECTIVE: We compared electron microscopic histologic changes of the radial artery grafts in non-diabetic and diabetic patients. METHODS: Thirty-six patients were divided into three groups according to their diabetic status (Group I had no diabetes mellitus [DM], Group II had type two DM and HbA1c levels were <7.5%, and Group III had type 2 DM but HbA1c levels were >7.5%). Distal parts of radial artery grafts were evaluated with scanning electron microscopy in a blind fashion by two histologists. Electron microscopic scores were compared among the groups. RESULTS: Radial artery electron microscopic scores were significantly different between group 1, 2 and 1, 3 and 2, 3 (p = 0.028, p < 0.001, and p < 0.001). In linear regression analysis, duration of DM (p = 0.027) and fasting plasma glucose (p = 0.001) were found as independent risk factors for histologic changes of radial artery grafts. CONCLUSION: Duration of DM and poor glycemic control were found to be associated with radial artery electron microscopic changes. doi: 10.1111/jocs.12761 (J Card Surg 2016;31:410-415).

Thoracic Grafts May Be an Alternative in Abdominal Aortic Aneurysm with Hostile Neck Anatomy.

In cases with a proximal aneurysm neck diameter of higher than 28 mm, standard endovascular aneurysm repair is considered inappropriate. In the present study, we report a successful endovascular treatment using overlapped thoracic and abdominal grafts technique in a patient whose infrarenal aneurysm neck diameter is 38.1 mm.

Clinical SYNTAX Score Can Predict Acute Kidney Injury following On-Pump but Not Off-Pump Coronary Artery Bypass Surgery.

BACKGROUND: The complexity of coronary artery disease is usually a neglected factor in risk stratification systems. We aimed to analyze the discriminative ability of the clinical SYNTAX score (CSS) for acute kidney injury (AKI) following on- and off-pump coronary artery surgery. METHODS: A total of 193 patients were reviewed in this study. Patients were divided into two groups according to the surgical procedure (group I: off-pump coronary artery bypass grafting, n = 89; group II: on-pump coronary artery bypass grafting, n = 104). Preoperative demographic data, the CSS and postoperative renal functions were evaluated. The postoperative AKI classification was made using the RIFLE (Risk, Injury, Failure, Loss of function, and End-stage renal disease) criteria. RESULTS: Postoperative AKI occurred in 14 of 89 patients (15.7%) in group I and in 29 of 104 patients in group II (27.8%; p = 0.046). The CSS did not vary much between the groups (31.52 ± 13.08 vs. 29.89 ± 15.70; p = 0.638). In group I, the CSS was not different between patients with AKI and those without AKI (30.167 ± 3.93 vs. 31.91± 14.75; p = 0.78). In group II, the CSS was 36.85 ± 18.33 in patients with AKI and 28.02 ± 12.32 in those without, and the difference was significant (p = 0.02). The discriminative ability of the CSS for postoperative AKI using the AUC analysis was 0.500 in group I and 0.840 in group II. CONCLUSION: The CSS may be a simple and successful means of risk prediction of postoperative AKI in on-pump coronary artery surgery.

Inflammation and congenital heart disease associated pulmonary hypertension.

BACKGROUND: Increased blood flow may trigger pulmonary arterial wall inflammation, which may influence progression of pulmonary artery hypertension in patients with congenital heart disease. In this study, we aimed to investigate the correlation between preoperative inflammation markers and pulmonary arterial hypertension. METHODS: A total of 201 patients with pulmonary hypertension were enrolled in this study retrospectively; they had undergone open heart surgery between January 2012 and December 2013. Patients' preoperative C-reactive protein (CRP), neutrophil to lymphocyte ratio, red blood cell distribution width, pulmonary pressures, and postoperative outcomes were evaluated. RESULTS: Patient age, neutrophil to lymphocyte ratio, red blood cell distribution width, and CRP were found to be significantly correlated with both preoperative peak and mean pulmonary artery pressures. These data were entered into a linear logistic regression analysis. Patient age, neutrophil to lymphocyte ratio, and CRP were found to be independently correlated with peak pulmonary pressure (P < .001, P < .001, and P = .004) and mean pulmonary artery pressure (P < .001, P < .001, and P = .001), whereas preoperative mean pulmonary artery pressure was found to be independently correlated with intensive care unit stay (P < .001). No parameter was found to be significantly correlated with extubation time and mortality. Eighteen patients had experienced pulmonary hypertensive crisis; in this subgroup, patients' mean pulmonary artery pressure and neutrophil to lymphocyte ratio were found to be significant (P = .047, P = .003). CONCLUSIONS: Preoperative inflammation markers may be correlated with the progression of pulmonary hypertensive disease, but further studies with larger sample size are needed to determine the predictive role of these markers for postoperative outcomes.

A giant dissecting aneurysm of ascending aorta following aortic valve replacement.

Ascending aortic dissection and aneurysm are rare but life-threatening complications after aortic valve replacement. Preoperative evaluation of risk factors such as aortic diameter, structural features of aortic wall, and associated diseases may decrease complication rate. We herein present analysis of risk factors of proximal aortic events following aortic valve replacement based on patient with giant dissecting aneurysm who underwent modified Bentall procedure.

Hybrid approach in patients with recurrent brachial artery embolism: adjunctive tissue plasminogen activator infusion following embolectomy.

Acute ischemia of an upper extremity occurs less frequently than vascular events of the leg and accounts for 15%-32% of all cases. Embolectomy provides prompt and effective treatment in the majority of cases. Recurrence of embolism and failed reperfusion can result in poor outcomes, even extremity loss. Adjunctive managements become important in this patient group. In this report, we present percutaneous intraarterial drip tissue plasminogen activator infusion to rescue the extremity in a patient with small cell lung cancer who experienced thromboembolism an additional six times following embolectomy.

Long-term prognosis of mild functional tricuspid regurgitation after mitral valve replacement.

OBJECTIVE: Functional tricuspid regurgitation (FTR) is the most common type of tricuspid insufficiency and occurs approximately in 30% of patients with mitral valve disease. The major etiologic factor in the triggering of right ventricular dilation and thus causing functional tricuspid regurgitation, is pulmonary artery hypertension secondary to mitral valve disease. We aimed to analyze long-term outcomes of patients with mild tricuspid regurgitation at the time of mitral valve replacement. METHODS: Sixty-six patients with mild tricuspid insufficiency who underwent mitral valve replacement were included in this observational retrospective study. Mean follow-up time was 8.3 ± 0.7 years. Patients whose tricuspid regurgitation remained unchanged or decreased following operation were enrolled to group 1 (n=32), patients whose tricuspid regurgitation increased were included to group 2 (n=34) and data were compared statistically with t-test, Mann-Whitney U, Chi-square and Fisher Exact test. Multiple regression analysis was performed to determine independent risk factors for FTR progression. REESULTS:Preoperatively female gender (p=0.02), body surface area (p=0.04), left atrium diameter (p=0.01), functional capacity (p=0.03), right ventricle diameter (p=0.04), and left ventricle mass index (p=0.04) were found to be statistically significant between groups. In the follow-up; functional capacity, grade of tricuspid insufficiency, pulmonary artery pressure, vena contracta width (p<0.001), TAPSE (tricuspid annular plane systolic excursion index) (p=0.04), annulus diameter (p=0.02), right ventricle diameter (p=0.01), left ventricle mass index (p=0.05), and ejection fraction (p=0.02) were found to be statistically different between groups. In multiple logistic regression analysis; preoperative LA diameter (OR=5.05; 95% CI:1.49-17.12; p=0.009) and female gender (OR=10.93; 95% CI:1.77-67.31; p=0.01) were found as independent risk factors for FTR progression. CONCLUSION: This study revealed that mild FTR might advance to moderate to severe grade in more than half of the patients in the follow-up. Thus, surgical approach to even mild FTR should be individualized based on patient's risk assessment.

Prolidase activity in patients with coronary artery aneurysm.

Decreased collagen biosynthesis and increased collagenolysis may induce aneurysmal progress in arterial walls. Prolidase plays a role in collagen synthesis. In this study, we sought to evaluate whether there is a correlation between nonatherosclerotic coronary artery aneurysms (CAAs) and prolidase activity. A total of 174 CAAs were diagnosed in 144 (2.1%) patients among 6845 coronary angiographies performed between 2009 and 2012. In all, 23 (15.9%) patients had nonatherosclerotic aneurysms. Prolidase activity was compared to the results of 19 healthy volunteers with normal coronary arteries. Demographic parameters were similar between the groups. Mean prolidase activity was 241.6 ± 54.4 mU/mL in the coronary aneurysm group and 730.3 ± 243.1 mU/mL in the control group (P < .001). The incidence of CAAs ranges between 0.3% and 5.3% in the general population. Decreased prolidase activity may reduce collagen biosynthesis that may contribute to aneurysm formation.

Electron microscopic evaluation of internal thoracic artery endothelial morphology in diabetic coronary bypass patients.

BACKGROUND: Diabetes is a well- identified major risk factor for cardiovascular diseases. This study was performed to evaluate the effect of diabetes and impact of glycemic control on internal thoracic artery (ITA) morphology by electron microscopy. METHODS: Thirty patients scheduled for coronary artery bypass grafting were enrolled in this study. Samples of ITA were taken during the surgery for electron microscopic evaluation. Group I (n = 10) consisted of diabetics who have poor glycemic control (HbA1c > 7.5%), group II (n = 10) of well-regulated (HbA1c = 4.4% to 6.2%) diabetic patients, and group III (n = 10) of nondiabetic patients. Samples were prepared as ultrathin sections and an original semiquantitative method of scoring was applied to describe the morphologic changes of endothelium. Final scores were analyzed with analysis of variance and post hoc analysis. RESULTS: In group I large vacuoles, swollen mitochondria were seen in endothelial cells and subendothelial edema was prominent. Endothelia (2.5 ± 1.2), arterial wall (2.0 ± 0.0), and endothelial mitochondria (2.9 ± 1.3) scores of group I were significantly higher than the other 2 groups (p < 0.001). The samples of group II and group III did not show significant differences with each other. The correlation between HbA1c values and total endothelial scores statistically significant (r = 0.912; p < 0.001). CONCLUSIONS: There is a correlation between HbA1c values and morphologic changes of ITA graft. Uncontrolled diabetes is an important predictor of morphologic changes evidenced by the ultrastructural findings. These ultrastructural changes were not as prominent in the diabetes mellitus patients with well controlled metabolic statuses and patients without diabetes.

Direct innominate artery cannulation in surgery for annuloaortic ectasia.

INTRODUCTION: The selection of the ideal cannulation site is still one of the major concerns in ascending aortic surgery. In the last decade, many surgeons have chosen to utilize antegrade cerebral perfusion in hypothermic circulatory arrest. In this study, we aimed to evaluate arterial cannulation techniques in patients who underwent root replacement for annuloaortic ectasia. MATERIALS AND METHODS: Between 2005 and 2012, a total of 69 patients with a diagnosis of annuloaortic ectasia underwent aortic root replacement with femoral artery, axillary artery, and direct innominate artery cannulation (IAC). Patients demographic, operative, and postoperative data were collected prospectively and analyzed. RESULTS: A total of 69 patients were investigated. Their ages varied from 13 to 78 (mean age was 54.25 ± 15.69) and 48 patients were male (69.5%). Mean aortic diameter was 5.65 ± 1.58 cm (min: 4.5 cm to max: 7.8 cm) by computerized tomography. The procedures included modified Bentall operation in 61 patients, and Cabrol operation in eight patients. In hospital, the mortality rate was 1.85%, and a 30-day mortality rate was 3.7% in the IAC group and 6.6% in patients who underwent femoral and axillary artery cannulation. Temporary cognitive dysfunction and stroke rate were similar between groups. CONCLUSION: Innominate cannulation is associated with low morbidity and mortality in patients who underwent ascending aorta surgery.