Primary graft dysfunction in heart transplantation: the challenge to survival.

Primary graft dysfunction (PGD) is a life-threatening clinical condition with a high mortality rate, presenting as left, right, or biventricular dysfunction within the initial 24 h following heart transplantation, in the absence of a discernible secondary cause. Given its intricate nature, definitive definition and diagnosis of PGD continues to pose a challenge. The pathophysiology of PGD encompasses numerous underlying mechanisms, some of which remain to be elucidated, including factors like myocardial damage, the release of proinflammatory mediators, and the occurrence of ischemia-reperfusion injury. The dynamic characteristics of both donors and recipients, coupled with the inclination towards marginal lists containing more risk factors, together contribute to the increased incidence of PGD. The augmentation of therapeutic strategies involving mechanical circulatory support accelerates myocardial recovery, thereby significantly contributing to survival. Nonetheless, a universally accepted treatment algorithm for the swift management of this clinical condition, which necessitates immediate intervention upon diagnosis, remains absent. This paper aims to review the existing literature and shed light on how diagnosis, pathophysiology, risk factors, treatment, and perioperative management affect the outcome of PGD.

Determinants of survival following heart transplantation in adults with congenital heart disease.

BACKGROUND: Adult patients surviving with congenital heart disease (ACHD) is growing. We examine the factors associated with heart transplant outcomes in this challenging population with complex anatomy requiring redo-surgeries. METHODS: We reviewed the United Network for Organ Sharing-Standard Transplant Analysis and Research database and analyzed 35,952 heart transplants from January 1st, 2000, to September 30th, 2018. We compared transplant characteristics for ischemic cardiomyopathy (ICM) (n = 14,236), nonischemic cardiomyopathy (NICM) (n = 20,676), and ACHD (n = 1040). Mean follow-up was 6.20 ± 4.84 years. Kaplan-Meier survival curves and Cox-proportional hazards analysis were used to analyze survival data. RESULTS: Multivariable analysis confirmed that ACHD was associated greater in-hospital death compared to ICM (HR = 0.54, P < 0.001) and NICM (HR = 0.46, P < 0.001). Notable factors associated with increased mortality were history of cerebrovascular disease (HR = 1.11, P = 0.026), prior history of malignancy (HR = 1.12, P = 0.006), pre-transplant biventricular support (HR = 1.12, P = 0.069), postoperative stroke (HR = 1.47, P < 0.001) and postoperative dialysis (HR = 1.71, P < 0.001). ACHD transplants had a longer donor heart ischemic time (P < 0.001) and trend towards more deaths from primary graft dysfunction (P = 0.07). In-hospital deaths were more likely with ACHD and use of mechanical support such as use of right ventricular assist device (HR = 2.20, P = 0.049), biventricular support (HR = 1.62, P < 0.001) and extracorporeal membrane oxygenation (HR = 2.36, P < 0.001). Conditional survival after censoring hospital deaths was significantly higher in ACHD (P < 0.001). CONCLUSION: Heart transplant in ACHD is associated with a higher post-operative mortality given anatomical complexity but a better long-term conditional survival. Normothermic donor heart perfusion may improve outcomes in the ACHD population by reducing the impact of longer ischemic times.

Surgical Treatment of Pediatric Refractory Ventricular Tachycardia Originating From a Left Ventricular Rhabdomyoma.

Cardiac tumors are very rare in children, and echocardiography is very important in their detection. The clinical presentation can vary greatly depending on arrhythmia or obstruction. One of the most important factors determining the surgical approach is the clinical process. In this case report, we report the surgical treatment of a rhabdomyoma that caused refractory ventricular tachycardia.

Minimally invasive multi-vessel coronary artery bypass grafting and concomitant mitral valve replacement via bilateral mini-thoracotomy: An alternative to sternotomy.

Minimally invasive methods continue to become increasingly common in cardiac surgery. In particular, the utilization of thoracotomy in multi-vessel coronary bypass grafting and valve surgery has accelerated, but sternotomy is still applied in combined pathologies. A 76-year-old male patient underwent multi-vessel coronary artery bypass grafting and mitral valve replacement without sternotomy using bilateral mini-thoracotomy, as the patient was old, frail, and had many comorbid factors. In conclusion, this minimally invasive approach can decrease all postoperative complications, accelerate patient recovery, and achieve good cosmetic results.

Pediatric Bentall procedure for giant ascending aortic aneurysm in Loeys-Dietz syndrome.

Ascending aortic aneurysm is very rare in children, and is usually seen in patients with underlying connective tissue disorders such as Marfans and Ehler-Danlos syndrome. Loeys-Dietz syndrome (LDS) is less commonly seen as a cause of ascending aortic aneurysms in children. In this case report, we describe pediatric Bentall procedure, which we successfully performed to a child with LDS (Type I) with giant ascending aortic enlargement and significant aortic regurgitation.

Preoperative passive venous pressure-driven cardiac function determines left ventricular assist device outcomes.

BACKGROUND: Right heart output in heart failure can be compensated through increasing systemic venous pressure. We determined whether the magnitude of this "passive cardiac output" can predict LVAD outcomes. METHODS: This was a retrospective review of 383 patients who received a continuous-flow LVAD at the University of Michigan between 2012 and 2021. Pre-LVAD cardiac output driven by venous pressure was determined by dividing right atrial pressure by mean pulmonary artery pressure, multiplied by total cardiac output. Normalization to body surface area led to the passive cardiac index (PasCI). The Youden J statistic was used to identify the PasCI threshold, which predicted LVAD death by 2 years. RESULTS: Increased preoperative PasCI was associated with reduced survival (hazard ratio [HR], 2.27; P < .01), and increased risk of right ventricular failure (RVF) (HR, 3.46; P = .04). Youden analysis showed that a preoperative PasCI ≥0.5 (n = 226) predicted LVAD death (P = .10). Patients with PasCI ≥0.5 had poorer survival (P = .02), with a trend toward more heart failure readmission days (mean, 45.09 ± 67.64 vs 35.13 ± 45.02 days; P = .084) and increased gastrointestinal bleeding (29.2% vs 20.4%; P = .052). Additionally, of the 97 patients who experienced readmissions for heart failure, those with pre-LVAD implantation PasCI ≥0.5 were more likely to have more than 1 readmission (P = .05). CONCLUSIONS: Although right heart output can be augmented by raising venous pressure, this negatively impacts end-organ function and increases heart failure readmission days. Patients with a pre-LVAD PasCI ≥0.5 have worse post-LVAD survival and increased RVF. Using the PasCI metric in isolation or incorporated into a predictive model may improve the management of LVAD candidates with RV dysfunction.

Evaluation of anastomosis quality with intraoperative transit time flowmeter in minimally invasive multi-vessel coronary artery bypass grafting via left anterior mini-thoracotomy.

Background: In this study, we aimed to describe our intraoperative transit-time flow measurement results as an integral component of the operation and evaluate the graft patency and anastomosis quality in patients who underwent minimally invasive multi-vessel coronary artery bypass grafting via mini-thoracotomy. Methods: Between May 2020 and September 2021, a total of 45 consecutive patients (32 males, 13 females; mean age: 51.2±8.6 years; range, 41 to 72 years) who underwent minimally invasive multi-vessel coronary artery bypass grafting via left anterior mini-thoracotomy were retrospectively analyzed. We used the technique of intraoperative transit-time flowmetry in all patients. The patients were operated under cardiopulmonary bypass. A saphenous vein graft was used in all anastomoses, except for the left internal thoracic artery. Results: The mean left internal mammary artery flow rate was 36.2±14.1 mL/min, mean flow rate of the diagonal grafts was 48.2±13.1 mL/min, mean flow rate of the circumflex grafts was 41.2±21.1 mL/min, and mean flow rate of the right coronary artery grafts was 52.2±11.3 mL/min. Wave patterns and flow parameters of all grafts were normal in the intraoperative measurements, since the pulsatility index values in all anastomoses were within normal limits. The operation was completed after anastomotic openings and graft patency were ensured. Conclusion: The use of an intraoperative flowmeter to show the graft patency and anastomosis quality gives confidence both to the surgeon and the patient. In multi-vessel coronary artery bypass grafting via mini-thoracotomy, anastomosis quality can be evaluated well with this technique.

Three Different Strategies for Repair of Symptomatic or Aneurysmatic Aberrant Right Subclavian Arteries

ABSTRACT Introduction: In this study, we aimed to present three different methods for symptomatic aberrant right subclavian artery (ARSA) surgery. Methods: We identified 11 consecutive adult patients undergoing symptomatic and/or aneurysmal ARSA repair between January 2016 and December 2020. Symptoms were dysphagia (n=8) and dyspnea + dysphagia (n=3). Six patients had aneurysm formation of the ARSA (mean diameter of 4.2 cm [range 2.8 - 6.3]). All data were analyzed retrospectively. Results: Median age of the patients (7 females/4 males) was 55 years (range 49 - 62). The first four patients (36.4%) underwent hybrid repair using thoracic endovascular aortic repair (TEVAR) and bilateral carotid-subclavian artery bypass (CScBp). Three patients (27.2%) were treated by open ARSA resection/ligation with left mini posterolateral thoracotomy (LMPLT) and right CScBp. And the last four patients (36.4%) underwent ARSA resection/ligation with LMPLT and ascending aorta-right subclavian artery bypass with upper mini sternotomy (UMS). Two of the four patients who underwent TEVAR + bilateral CScBp had continuing dysphagia cause of persistent esophageal compression. Brachial plexus injury developed in one of three patients who underwent LMPLT + right CScBp. Pleural effusion treated with thoracentesis alone was observed in one of four patients who underwent UMS + LMPLT. Conclusion: Among the symptomatic and/or aneurysmal ARSA treatment approaches, surgical and hybrid methods are used. There is still no consensus on how to manage these patients. In our study, we recommend the UMS + LMPLT method, since the risk of complications with anatomical bypass is less, and we have more successful surgical results.

Three Different Strategies for Repair of Symptomatic or Aneurysmatic Aberrant Right Subclavian Arteries.

INTRODUCTION: In this study, we aimed to present three different methods for symptomatic aberrant right subclavian artery (ARSA) surgery. METHODS: We identified 11 consecutive adult patients undergoing symptomatic and/or aneurysmal ARSA repair between January 2016 and December 2020. Symptoms were dysphagia (n=8) and dyspnea + dysphagia (n=3). Six patients had aneurysm formation of the ARSA (mean diameter of 4.2 cm [range 2.8 - 6.3]). All data were analyzed retrospectively. RESULTS: Median age of the patients (7 females/4 males) was 55 years (range 49 - 62). The first four patients (36.4%) underwent hybrid repair using thoracic endovascular aortic repair (TEVAR) and bilateral carotid-subclavian artery bypass (CScBp). Three patients (27.2%) were treated by open ARSA resection/ligation with left mini posterolateral thoracotomy (LMPLT) and right CScBp. And the last four patients (36.4%) underwent ARSA resection/ligation with LMPLT and ascending aorta-right subclavian artery bypass with upper mini sternotomy (UMS). Two of the four patients who underwent TEVAR + bilateral CScBp had continuing dysphagia cause of persistent esophageal compression. Brachial plexus injury developed in one of three patients who underwent LMPLT + right CScBp. Pleural effusion treated with thoracentesis alone was observed in one of four patients who underwent UMS + LMPLT. CONCLUSION: Among the symptomatic and/or aneurysmal ARSA treatment approaches, surgical and hybrid methods are used. There is still no consensus on how to manage these patients. In our study, we recommend the UMS + LMPLT method, since the risk of complications with anatomical bypass is less, and we have more successful surgical results.

Routine minimally invasive approach via left anterior mini-thoracotomy in multivessel coronary revascularization.

BACKGROUND: Minimally invasive heart surgery continues to spread rapidly around the world. Although coronary artery bypass surgery with median sternotomy continues to be performed intensively in many centers, the results of the new literature continue to contribute to proving the reliability of minimally invasive coronary surgery. In this study, we aimed to contribute to the routine feasibility of minimally invasive coronary bypass with left anterior mini-thoracotomy with our own case series. METHODS: From July 2019 to August 2021 a total of 184 nonselected consecutive patients underwent minimally invasive on-pump multivessel coronary artery bypass grafting through the left anterior minithoracotomy in the fourth intercostal space. In the operation decision; regardless of low ejection fraction, morbid obesity, number of diseased vessels, or other comorbid factors, bypass operation was performed routinely via thoracotomy without selecting patients, except redo patients or porcelain aorta. The mean number of grafts was 3.3 ± 0.5. Left internal mammary artery was used in all patients. For other anastomoses; saphenous vein graft was used. Cardiopulmonary bypass (CPB), aortic cross-clamping, and blood cardioplegia were used in all patients. Postoperative results of all patients were analyzed retrospectively. RESULTS: The total CPB time was 144.5 ± 27.3 min, and aortic cross-clamp time 82.1 ± 16.2 min. The mean intensive care stay was 1.2 ± 0.7 days and mean total hospital stay 5.1 ± 1.2 days. Total perioperative mortality was 0.54% (one patient). Myocardial infarction was not observed in any case in the postoperative period. The cause of mortality was delayed tamponade occurring on the fifth postoperative day. Nine patients underwent revision due to bleeding in the early postoperative period. There was no patient who underwent stroke or developed renal failure requiring hemodialysis in the postoperative period. One hundred and eighty-three patients (99.4%) were discharged with good recovery. CONCLUSION: Minimally invasive multivessel bypass surgery is a surgical method that has just started to become widespread. The fact that the technique is new and more challenging than conventional methods makes it difficult for surgeons to adopt it. In addition, one of the most important issues is that the surgical results should be satisfactory. Our study shows that safe, successful, and satisfactory results can be obtained by using this method, as in our case series. In addition, we think that it can be successfully applied routinely to all patients without distinction.

Direct bilateral carotid artery cannulation can be better strategy for acute aortic dissection involving both carotid arteries.

Although acute aortic dissections with bilateral carotid artery involvement are rare, they have serious morbidity and mortality rates. The most important strategy in cases with carotid involvement is to provide adequate cerebral perfusion during cardiopulmonary bypass. In this case, we presented, aortic dissection with bilateral carotid involvement was detected in the patient who was admitted to the emergency department with severe chest pain, vision loss, and left arm monoplegia, and the decision for surgery was made urgently. Selective cerebral perfusion was provided throughout the operation with direct bilateral carotid cannulation, in terms of being the fastest method and providing adequate cerebral flow. During the discharge period, full recovery was achieved in neurological deficits without any sequelae. We think that the technique we have applied in such a difficult and complicated case is the best strategy because it is fast and effective.

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

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

Effects of N-Acetylcysteine and N-Acetylcysteine Amide on Erythrocyte Deformability and Oxidative Stress in a Rat Model of Lower Extremity Ischemia-Reperfusion Injury.

N-acetylcysteine (NAC) is an antioxidant which works as a free radical scavenger and antiapoptotic agent. N-acetylcysteine-amide (NACA) is a modified form of NAC containing an amide group instead of a carboxyl group of NAC. Our study aims to investigate the effectiveness of these two substances on erythrocyte deformability and oxidative stress in muscle tissue. Materials and Methods. A total of 24 Wistar albino rats were used in our study. The animals were randomly divided into five groups as control (n: 6), ischemia (n: 6), NAC (n: 6), and NACA (n: 6). In the ischemia, NAC, and NACA groups, 120 min of ischemia and 120 min of reperfusion were achieved by placing nontraumatic vascular clamps across the abdominal aorta. The NAC and NACA groups were administered an injection 30 min before ischemia (100 mg/kg NAC; 100 mg/kg NACA; intravenous). Blood samples were taken from the animals at the end of the ischemic period. The lower extremity gastrocnemius muscle was isolated and stored at -80 degrees to assess the total antioxidant status (TAS), total oxidant status (TOS), and oxidative stress index (OSI) values and was analyzed. Results. The erythrocyte deformability index was found to be statistically significantly lower in rats treated with NAC and NACA before ischemia-reperfusion compared to the groups that received only ischemia-reperfusion. In addition, no statistically significant difference was found between the control group and the NAC and NACA groups. The groups receiving NAC and NACA before ischemia exhibited higher total antioxidative status and lower total oxidative status while the oxidative stress index was also lower. Conclusion. The results of our study demonstrated the protective effects of NAC and NACA on erythrocyte deformability and oxidative damage in skeletal muscle in lower extremity ischemia-reperfusion. NAC and NACA exhibited similar protective effects on oxidative damage and erythrocyte deformability.

An unexpected and rare complication after endovenous laser ablation: Pyoderma gangrenosum.

Pyoderma gangrenosum is a rare inflammatory ulcerative skin disease characterized by painful, progressive necrosis of wound margins. A 34-year-old male patient was admitted to our clinic with progressive ulcerative lesion at the wound site after endovenous laser ablation and varicose vein surgery. Although parenteral antibiotherapy was initiated with the diagnosis of wound infection, rapid progression was observed in the lesion. Skin biopsy was performed, and the patient was started on empirical prednisolone treatment with the diagnosis of pyoderma gangrenosum. Complete healing was achieved in the lesion. In conclusion, pyoderma gangrenosum should be considered in the differential diagnosis of postoperative delayed wound healing.

Redo robotic cardiac surgery and concomitant cesarean section in a pregnant patient with dextrocardia and situs inversus totalis.

Reoperations in cardiac surgery are very difficult and risky operations due to possible complications. A 35-week pregnant, 27-year-old woman patient presented to the cardiology department with palpitations. Control transthoracic echocardiography revealed a mass in the right atrium with dimensions of 24 × 25 mm. The patient had dextrocardia and situs inversus totalis, and had undergone a robotic atrial septal defect repair operation 1 year ago. Operation was planned for the patient with the joint decision of cardiology, obstetrics, pediatrics, anesthesia, and cardiovascular surgery departments. Redo robotic heart surgery was performed in beating heart after the operation of the cesarean, and the mass in the right atrium was successfully removed. In conclusion, as it is seen in our case, robotic cardiac surgery can be safely and successfully performed, and can minimize morbidity and mortality even in very complex clinical conditions such as pregnancy, dextrocardia, and reoperation.

An unexpected complication of robotic cardiac surgery: Pneumomediastinum.

Pneumomediastinum is a rare entity that is defined as free air in the mediastinal space. A 26-year-old male patient was admitted with pneumomediastinum as an unexpected complication of robotic surgery. Diffuse subcutanous emphysema was observed suddenly on Postoperative Day 3 without respiratory distress. Air trapping into the mediastinum was seen on chest X-ray and computed tomography. The patient was followed in the intensive care unit for 7 days and managed conservatively. Subcutaneous emphysema reduced gradually. In conclusion, although it is a rare condition, pneumomediastinum should be kept in mind as a complication of robotic cardiac surgery.