Long-term outcomes of TEVAR for thoracic aortic diseases: a retrospective single-center study.

BACKGROUND: The outcomes of Thoracic Endovascular Aortic Repair (TEVAR) vary depending on thoracic aortic pathologies, comorbidities. This study presents our comprehensive endovascular experience, focusing on exploring the outcome in long term follow-up. METHODS: From 2006 to 2018, we conducted TEVAR on 97 patients presenting with various aortic pathologies. This retrospective cohort study was designed primarily to assess graft durability and secondarily to evaluate mortality causes, complications, reinterventions, and the impact of comorbidities on survival using Kaplan-Meier and Cox regression analyses. RESULTS: The most common indication was thoracic aortic aneurysm (n = 52). Ten patients had aortic arch variations and anomalies, and the bovine arch was observed in eight patients. Endoleaks were the main complications encountered, and 10 of 15 endoleaks were type I endoleaks. There were 18 reinterventions; the most of which was TEVAR (n = 5). The overall mortality was 20 patients, with TEVAR-related causes accounting for 12 of these deaths, including intracranial bleeding in three patients. Multivariant Cox regression revealed chronic renal diseases (OR = 11.73; 95% CI: 2.04-67.2; p = 0.006), previous cardiac operation (OR = 14.26; 95% CI: 1.59-127.36; p = 0.01), and chronic obstructive pulmonary diseases (OR = 7.82; 95% CI: 1.43-42.78; p = 0.001) to be independent risk factors for 10-year survival. There was no significant difference in the survival curves of the various aortic pathologies. In the follow-up period, two non-symptomatic intragraft thromboses and one graft infection were found. CONCLUSION: Comorbidities can increase the risk of TEVAR-related mortality without significantly impacting endoleak rates. TEVAR is effective for severe aortic pathologies, though long-term graft durability may be compromised by its thrombosis and infection.

Selective cerebral extracorporeal circulation-enhanced total endovascular arch replacement using in situ fenestration.

In this article, we present a newly designed cerebral perfusion technique during the in situ fenestration procedure with three covered stent placement in an endovascular total aortic arch repair of a 68-year-old male patient. This technique enables the endovascular repair of the ascending aorta and aortic arch pathologies with commonly available thoracic aorta stent grafts in a safer and more effective manner.

Intrapericardial goiter.

Intrapericardial goiter cases are only a few in the literature. We present a 53-year-old woman who was operated for 8-cm anterior mediastinal mass located completely intrapericardial and histopathological examination revealed an ectopic goiter. It may be difficult to distinguish between mediastinal masses within or outside the pericardium. Thoracoscopy may be needed in such cases.

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.

Results of late-onset type A aortic dissection after previous cardiac surgery: Does prior coronary artery bypass grafting affect survival?

BACKGROUND: This study aims to evaluate the results of late-onset type A aortic dissection following primary cardiac surgery and to compare the outcomes of patients with or without prior coronary artery bypass grafting. METHODS: Between January 2005 and December 2015, data of 32 patients (16 males, 16 females; mean age 58.1±10.9 years; range, 45 to 73 years) who were diagnosed with acute type A aortic dissection and underwent repair with a history of previous cardiac surgery at our institution were retrospectively analyzed. The patients were divided into two groups as those with a history of prior coronary artery bypass grafting (n=16) and the patients with a previous cardiac surgery without prior coronary artery bypass grafting (n=16). RESULTS: Dissection of the ascending aorta occurred in 32 patients (late acute in 22 and late chronic in 10) who underwent previous cardiac surgery (aortic valve replacement in 12, mitral valve replacement in two, aortic valve replacement + coronary artery bypass grafting in two, coronary artery bypass grafting in 10, mitral valve replacement + coronary artery bypass grafting in four, and dual valve replacement in two patients). The mean time between the first operation and dissection was 4.0±1.5 years. Dissections were treated with the Bentall procedures (n=8), ascending aorta replacement (n=14), ascending aorta replacement + hemiarch replacement (n=4), ascending aorta + aortic valve replacement (n=4) and Bentall + arch replacement (n=2). In-hospital mortality (30-day mortality) was seen in five patients, and oneyear mortality rate was 21.85% (n=7). The survival rates of the all patients for primary cardiac surgery vs primary cardiac surgery + coronary artery bypass grafting were 81.25% vs 75% at one year, 75% vs 68.75% at three years,75% vs 56.25% at five years, 68.75% vs 56.25% at seven years, and 68.75% vs 56.25% at 10 years, respectively (p=0.71, CI: 95%). CONCLUSION: Type-A aortic dissections may develop after cardiac operations with or without coronary artery bypass grafting at any time, and irrespective of associated histologies, they may result in high overall in-hospital mortality. With careful planning by prompt intervention, the outcomes in redo sternotomy operations with or without coronary artery bypass grafting for aortic dissections would be consistent the results of spontaneous aortic dissections.

Comparison of aortic cross-clamping versus beating heart surgery in tricuspid valve repair.

BACKGROUND: The aim of this study was to evaluate the clinical outcomes of tricuspid valve repair using aortic cross-clamping versus using beating heart surgery. METHODS: A total of 208 patients (67 males, 141 females; mean age 61.5±9.2 years; range, 29 to 81 years) who underwent concomitant cardiac surgery and tricuspid valve repair between January 2007 and January 2016 at a single center were included. Two surgical strategies for tricuspid valve repair with aortic cross-clamping (n=102) or on beating heart (n=106) were compared. Primary endpoints were in-hospital mortality and the rate of permanent pacemaker placement after surgery. Secondary endpoints were cross-clamp and cardiopulmonary bypass times, postoperative inotropic support, temporary pacemaker requirement, and residual tricuspid regurgitation at discharge and at one year. RESULTS: Overall hospital mortality was 7% (n=14) (cross-clamping 7% vs. beating heart 7%; p>0.05). The mean cross-clamp and cardiopulmonary bypass times were significantly longer in the aortic cross-clamping group (p=0.0001). Also, a higher number of patients in this group needed inotropic support (78/102) than the beating heart group (57/106) (p<0.05). The rate of postoperative left bundle branch block was higher in the cross-clamping group (14% vs. 5%, respectively; p<0.05). The rate of permanent pacemaker placement was also significantly higher in the cross-clamping group than the beating heart group (11.8% vs. 2.8%, respectively; p<0.05). At discharge, residual >2 tricuspid regurgitation was more commonly seen in the cross-clamping group (16% vs. 3%, respectively; p=0.0023). At one year of follow-up, residual >2 tricuspid regurgitation was present in 22 patients (23%) in the aortic crossclamping group and in eight patients (8%) in the beating heart group (p=0.0048). CONCLUSION: Tricuspid valve repair on beating heart offers less inotropic support and a lower rate of postoperative permanent pacemaker placement requirement and residual tricuspid regurgitation, although both techniques yield similar postoperative clinical outcomes. These results support the use of tricuspid valve repair on a beating heart in concomitant left-sided valvular heart surgery.

Effects of Preoperative Tricuspid Valve Diameters on Early Postoperative Surgical Outcomes in Patients Undergoing Tricuspid Valve Surgery.

BACKGROUND: Many of the previous studies on tricuspid valve surgery were on the materials that were used and the advantages and disadvantages of them. In this study, effects of preoperative tricuspid valve diameter on early postoperative outcomes were investigated. Methods: A total of 43 patients who underwent tricuspid valve repair surgery with the ring between the years 2012-2014 were included in this study. Tricuspid valve diameters and other cardiac functions of patients undergoing tricuspid intervention were evaluated with transthoracic echocardiography.Patients included in this study were divided into 2 groups: those with minimal, minimal-to-1st degree and 1st-degree tricuspid valve regurgitation found on thoracic echocardiography in the early postoperative period were considered as having a successful tricuspid repair (Group 1). Those with 1st-2nd degree and higher degrees of tricuspid regurgitation were considered as having an unsuccessful tricuspid repair (Group 2).The relationship between tricuspid valve dimensions and early tricuspid valve regurgitation was assessed with the help of preoperative, intraoperative, and postoperative data. RESULTS: Thirty patients (Group 1) were found to have a successful tricuspid valve repair in the postoperative period. The mean annulus diameter of the tricuspid valve at end-diastole in patients from Group 1 was similar to Group 2 (4.24 ± 0.44 cm versus 3.99 ± 0.40; P = .080). Also, tricuspid valve end-systolic diameter in Group 1 was similar to patients in Group 2 (3.59 ± 0.38 cm versus 3.42 ± 0.33 cm; P = .151). Conclusion: A direct relationship was not found between tricuspid valve diameter and post-operative development of moderate to severe regurgitation in tricuspid valve surgery in this study.

A Retrospective Analysis of Surgical Femoral Artery Closure Techniques: Conventional versus Purse Suture Technique.

BACKGROUND: Different techniques have been reported for the exploration and repair of femoral artery (FA) in patients who undergo minimally invasive cardiac surgery (MICS) and endovascular aortic surgery. We used a modified approach alternative to the conventional technique (group CT) since May 2013, which specifies a shorter groin incision and diamond-shaped hemostatic purse sutures for arteriotomy closure without the requirement of cross-clamping (group PT [purse suture technique]) and evaluated early outcomes and the complication profiles of the 2 techniques for femoral access. METHODS: In our clinic, between May 2011 and December 2015, 503 FA cannulations were performed on 345 patients who underwent MICS (n = 109, mean age 64.1 ± 17.6 years, female/male ratio 71/38), endovascular abdominal aneurysm repair (n = 158, mean age 71.3 ± 10.2 years, female/male ratio 63/95), thoracal endovascular aneurysm repair (n = 50, mean age 65.0 ± 15.3 years, female/male ratio 15/35), and transaortic valve implantation (n = 28, mean age 80.8 ± 5.9 years, female/male ratio 13/15). A total of 295 FAs were exposed via mini incision and were repaired with the PT. We compared the duration of femoral closure (FC), wound infection, and vascular complications including bleeding hematoma, thromboembolic and ischemic events, pseudoaneurysm, seroma, surgical reintervention rates, delayed hospital stay for groin complications, and existence of postoperative local luminal narrowing (LLN) at the intervention site over 25% for both groups. RESULTS: FC time (CT 14.9 ± 3.16 min, PT 6.5 ± 1.12 min, P < 0.0001), bleeding hematoma frequency (CT 6.2%, PT 1.7%, P = 0.01), and prolonged hospital stay for groin complications (CT 14.9%, PT 3.4%, P < 0.0001) were significantly lower in the PT group. Rate of technical success (CT 80.3%, PT 87.4%, P = 0.03) and event-free patient (CT 66.1%, PT 77.5%, P = 0.03) were significantly better in the PT group. There were no differences between groups in terms of ischemic events, wound infection rates, development of pseudoaneurysm and seroma, surgical reintervention rates, and LLN of FA over 25% at 6-month duplex evaluation. CONCLUSIONS: The comparison of the 2 approaches revealed the advantages of the PT in terms of bleeding hematoma and shortening in FC time and the length of hospital stay. We suggest performing a smaller skin incision for FA access and utilizing purse sutures, which allows completing the procedure without cross-clamping, thus providing a favorable approach and excellent comfort for the surgeon.

Abdominal aortic aneurysm causing lumbar vertebral erosion in Behçet's disease presenting by low back pain.

Behçet's disease (BD) is a chronic multi-system disorder commonly seen in Mediterranean, middle east and far eastern populations. In this report, we describe a case of a 55-year-old male with Behçet's disease who presented with a low back pain and sciatica. Imaging studies showed that he had a destruction of the third lumbar vertebra because of abdominal aortic aneurysm-related Behçet's disease. Aortic aneurysms with vertebral body erosion have been rarely reported, but this vascular complication is a life-threatening clinical picture. Therefore, among the causes of chronic lumbar pain in a BD patient, abdominal aortic aneurysm should be remembered.

Middle aortic syndrome in a teenager.

Middle aortic syndrome (MAS) is a rare pathology that involves diffuse/segmental narrowing of the distal thoracic or abdominal aorta. The most common clinical manifestation is severe hypertension, which requires multiple antihypertensive medications and/or surgical repair. We report the surgical repair of MAS in a 14-year-old male.

Left ventricular myxoma producing cardiac failure.

INTRODUCTION: Seventy-five percent of primary cardiac tumors are benign, and most are myxomas. Seventy-five percent of myxomas originate from the left atrium, and 2.5% arise from the left ventricle. Heart failure is a rare complication of myxoma. CASE: A 54-year-old male patient with chronic obstructive pulmonary disease was admitted to the pulmonology department with a diagnosis of pneumonia and congestive heart failure during hospitalization. An echocardiography evaluation revealed a mobile mass (3.3 cm X 1.2 cm) in the left ventricle. The measured ejection fraction was 22%. Transthoracic and transesophageal echocardiography and magnetic resonance imaging examinations confirmed the presence of a myxoma in the left ventricle. The myxoma was a hanging mass with a stalk on the interventricular septum near the anterior mitral valve annulus. We visualized the gelatinous fragile mass on the septum; we then extracted the myxoma via a transaortic approach with the patient on cardiopulmonary bypass. The patient was discharged 10 days after surgery. DISCUSSION: Myxoma is treated by early surgical resection because of the potential for serious complications. Left ventricular myxomas have been reported to lead to a silent heart failure. This case is important because of its location and the patient's resultant heart failure.

The efficacies of modified mechanical post conditioning on myocardial protection for patients undergoing coronary artery bypass grafting.

BACKGROUND: Coronary artery bypass grafting (CABG) with cardioplegic cardiac arrest and cardiopulmonary bypass (CPB) is associated with myocardial injury. The aim of this study was to investigate whether a modified mechanical post-conditioning (MMPOC) technique has a myocardial protective effect by enhancing early metabolic recovery of the heart following revascularization. METHODS: A prospective, randomized trial was conducted at a single-center university hospital performing adult cardiac surgery. Seventy-nine adult patients undergoing first-time elective isolated multivessel coronary artery bypass grafting were prospectively randomized to MMPOC or control group. Anesthetic, cardiopulmonary bypass, myocardial protection, and surgical techniques were standardized. The post reperfusion cardiac indices, inotrope use and biochemical-electrocardiographic evidence of myocardial injury were recorded. The incidence of postoperative complications was recorded prospectively. RESULTS: Operative characteristics, including CPB and aortic cross-clamp time, were similar between the two groups (p>0.05). The MMPOC group had lower troponin I and other cardiac biomarkers level post CPB and postoperatively, with greater improvement in cardiac indices (p<0.001). MMPOC shortened post surgery hospitalization from 9.1 ± 2.1 to 7.5 ± 1.6 days (p<0.001). CONCLUSIONS: MMPOC technique promotes early metabolic recovery of the heart during elective CABG, leading to better myocardial protection and functional recovery.

Giant posterolateral left ventricular aneurysm diagnosed 6 weeks after incomplete surgical revascularization.

We report the surgical repair of a true left ventricular aneurysm diagnosed 6 weeks after incomplete surgical revascularization.

A rare complication of radial artery catheterization.

An arterial pseudoaneurysm is a cavity which does not consist of three layers of arterial wall and is generally seen at femoral and radial artery sites due to bone fractures, arterial injuries and iatrogenic reasons such as catheterization. The treatment choice may be either surgical or conservative. Patients with pseudoaneurysm should be carefully followed and the treatment choice should be immediately decided to avoid possible complications. We report a case of pseudoaneurysm formation in the radial artery that occurred one week after arterial catheterization for coronary angiography. The treatment choice for this patient was surgical and he was discharged without any complications.

Effects of prophylactic indomethacin treatment on postoperative pericardial effusion after aortic surgery.

OBJECTIVE: This prospective, randomized study assessed the prophylactic effects of indomethacin treatment on pericardial effusion after aortic surgery. METHODS: Eighty-five patients were found eligible to participate in this double-blind study. Patients were assigned to a control group receiving oral placebo or to an indomethacin group receiving 25 mg oral indomethacin 3 times daily for 7 days preoperatively. After aortic surgery, patients were followed up clinically and evaluated for pericardial effusion with transthoracic echocardiography on the first and seventh postoperative days during hospitalization and at the second and sixth weeks after discharge. RESULTS: The demographic and the operative data were similar between groups. The surgical interventions included Bentall procedure in 63 patients, valve-sparing procedures in 7 patients, and supracoronary ascending aorta replacement in 15 patients. Hemiarch replacement was performed in 16 patients. No patient in either group had pericardial effusion after the first postoperative day. At the end of the first week, however, 2 patients had pericardial effusion, at the end of the second week after discharge, 3 patients had pericardial effusion, and at the end of the sixth week after discharge, 4 patients had PEs. One of the patients who had PE at the end of the sixth week received indomethacin; the others were all in the control group, a significant difference (P=.019). Five patients underwent transthoracic echocardiographically guided pericardiocentesis; 4 underwent surgical pericardiocentesis. CONCLUSIONS: Indomethacin may have beneficial effects on the outcomes and incidence of postoperative pericardial effusion after aortic surgery.

Pulmonary artery sarcoma mimicking pulmonary thromboembolism.

A 30 years old male patient was referred to our hospital with a diagnosis of pulmonary thromboembolism due to thorax-computerized tomography (CT) angiography, revealing a thrombus totally occluding left main pulmonary artery. The lesion was evaluated as tumoural mass. Positron emission tomography (PET)-CT revealed pathologic uptake at pulmonary artery mass. Due to localization of tumour, left pneumonectomy was performed. The pathological diagnosis revealed to be pulmonary artery sarcoma. The patient was presented because pulmonary artery sarcomas are very rare tumors and can mimick pulmonary thromboembolism. The true prevalence is underestimated as many pulmonary artery sarcomas are misdiagnosed as pulmonary thromboembolism. PET-CT may help to make a differential diagnosis.

Native valve Brucella endocarditis.

OBJECTIVE: Brucellosis is frequently seen in Mediterranean and Middle East countries, including Turkey. We report the medical and surgical management of 31 cases of native endocarditis. MATERIAL AND METHOD: Thirty-one patients were admitted to our clinic with suspected Brucella Endocarditis. The diagnosis was established by either isolation of Brucella species, or the presence of antibodies. Following preoperative antibiotic therapy patients underwent valve replacement with excessive tissue debridement. Patients were followed up with Brucella titers, blood cultures, and echocardiography. RESULTS: On admission all patients were febrile and mostly dyspneic (NYHA Class 3 or 4). The blood tests were normal except for elevated ESR, CRP and serological tests. The aortic valve was involved in 19 patients, mitral valve in 7 patients, and both valves in 5. After serological confirmation of BE, antibiotic therapy was maintained. Twenty-five of the patients received rifampicine, doxycycline, and cotrimaxozole; 2 of them received a combination of rifampicine, streptomycin, and doxycycline; and 4 of them received rifampicine, tetracycline, and cotrimaxozole. Tissue loss in most of the affected leaflets and vegetations were presenting all patients. Valve replacements were performed with mechanical and biologic prostheses. All the patients were afebrile at discharge but received the antibiotics for 101, 2+/-16, 9 days. The follow-up was 37, 1+/-9, 2 months. DISCUSSION: In our retrospective study, combination of adequate medical and surgical therapy resulted in declined morbidity and mortality rate. The valve replacement with aggressive debridement is the most important part of the treatment, which should be supported with efficient preoperative and long term postoperative medical treatment.

Vacuum-assisted closure and bilateral pectoralis muscle flaps for different stages of mediastinitis after cardiac surgery.

PURPOSE: To assess the results of bilateral pectoralis major muscle flaps (BPMMF) and vacuum-assisted closure (VAC) at different stages of postcardiac surgery mediastinitis. METHODS: Of 65 patients with a deep sternal wound infection (DSWI) after cardiac surgery, 33 with a stable sternum were treated with VAC (59.3 +/- 11.7 years of age) and 32 with an unstable sternum or osteomyelitis (63.3 +/- 9.8 years of age) were treated with early BPMMF and continuous irrigation. Delayed BPMMF reconstruction was necessary in six VAC patients. RESULTS: The overall incidence of DSWI was 1.04% within the study period. Deep sternal wound infection was diagnosed 15.9 +/- 10.8 days (range 5-62 days) after surgery. Diabetes was more common in the BPMMF group than in the VAC group (P = 0.046). Hospital mortality after treatment was 4.6% (n = 3) overall. Causes of death were septic multiorgan failure and respiratory failure. The infective pathogens were methicillin-resistant Staphylococcus aureus (MRSA; n = 2) and Acinetobacter species (n = 1). The median hospital stay was 29 days (range 15-110 days). After 6 months, only one recurrent sternal infection had occurred in the VAC group. CONCLUSIONS: Early BPMMF is an effective surgical treatment for DSWI in patients with an unstable sternum and osteomyelitis. VAC may be considered for patients without osteomyelitis but a stable sternum, or as adjuvant therapy in patients with comorbidity.

Effects of carbamazepine on spinal cord ischemia.

BACKGROUND: Prophylactic treatment with carbamazepine has been shown to reduce the cerebral damage and neurologic deficit in ischemic conditions. A randomized controlled study based on a rabbit model was designed to study the effect of carbamazepine on a spinal cord ischemic reperfusion injury. METHODS: Thirty New Zealand rabbits were randomly assigned to 1 of the 2 groups (n = 15 per group): group I (control group) and group II (carbamazepine group). Spinal cord ischemia was induced by infrarenal aortic crossclamp for 25 minutes in both groups. Functional evaluation with the Tarlov score during a 2-day observation period and histopathologic assessment of the lumbar spinal cord were performed. Changes in spinal cord morphology were observed with hematoxylin-eosin staining and electron microscopy. Gray matter damage was assessed on the basis of the number of normal neurons in the ventral horn. RESULTS: Diffuse destruction of gray matter with moderate to severe vacuolization and essentially no normal ganglion cells was observed in the spinal cord of rabbits in the control group, whereas specimens of rabbits assigned to the carbamazepine group showed ganglion cells with normal nuclei and cytoplasm (P < .0001). Neurologic impairment was significantly attenuated in the carbamazepine group compared with the Tarlov scores of the control group (P < .0001 at day 2). CONCLUSION: Carbamazepine may protect the spinal cord from ischemic reperfusion injury that is associated with ameliorated neurologic and histopathologic results.