Prognostic nutritional index predicts in-hospital mortality in patients with acute Stanford type A aortic dissection.

BACKGROUND: Acute Stanford type A aortic dissection (ATAAD) is a life-threatening medical emergency. The aim of this study was to investigate the clinical significance of the prognostic nutritional index (PNI) as a novel inflammatory marker for ATAAD patients undergoing surgical repair. METHODS: We retrospectively examined the medical records of 151 ATAAD patients who treated surgically. Patients were divided into two groups (survival and death) and these groups were compared with respect to clinical and laboratory parameters. The PNI was calculated as 10 × serum albumin (g/dL) + 0.005 × total lymphocyte count (per mm3). Logistic regression analyses were performed to identify the risk factors of in-hospital mortality. RESULTS: The mean age of the study cohort was 61 ± 12 years, 99 (65.6%) were males, and 35 (23.2%) patients died during the hospital stay. The PNI levels were significantly lower in death group compared with survival group (32.80 ± 4.90 vs. 37.94 ± 5.42, p < 0.001). Multivariate analysis showed that the PNI (OR: 0.795, p = 0.005), age (odds ratio [OR]: 1.085, p = 0.034), operating time (OR: 1.660, p = 0.042), and D-dimer (OR: 1.002, p = 0.001) independently predicted in-hospital mortality. The calculated cutoff value of the PNI was 33.01. CONCLUSION: Lower PNI values are independently associated with in-hospital mortality in ATAAD. The PNI may be a useful tool for predicting the early mortality of ATAAD patients after surgical repair.

Evaluation of the increase in invasive device associated infections in cardiovascular surgical intensive care unit.

INTRODUCTION: Infections related to the use of invasive instruments leads to the risk of treatment difficulties, prolonged hospitalization, increased health care costs, and increased mortality and morbidity rates. The present study examines the results of an infection surveillance study that showed an increased incidence of infections related to the use of invasive instruments in the cardiovascular surgery intensive care unit of the Ankara Training and Research Hospital and mitigating measures were taken following the surveillance program. METHODOLOGY: Compared with previous surveillance data, an increase was observed in the incidence of infections related to the use of invasive instruments in cardiovascular surgery intensive care unit (CVS-ICU) during the first six months of 2014. A research team was formed comprising one infectious diseases and microbiology specialist, one cardiovascular surgeon, and two infection-control nurses. Patient data was collected. The compliance of the surgeons, nurses, and other health care professionals to the infection control measures was evaluated. RESULTS: The rate of ventilator-associated pneumonia was 8.20% and the rate of catheter-associated urinary tract infection was 4.47% in the CVS-ICU. There were missing or inadvertent practices regarding antibiotic prophylaxis, asepsis and antisepsis and isolation measures in patient preparation and patient care before and after the operations. The rate of inappropriate antibiotic as prolonged use was 72%. CONCLUSIONS: It is one of the basic tasks to take appropriate measures to prevent outbreaks of hospital infections. It is possible to prevent an outbreak of hospital infections only by the accurate analysis of data and establishing strict infection control procedures.

Tricuspid Valve Replacement Through Right Thoracotomy has Better Outcomes in Redo Cases.

BACKGROUND: The tricuspid valve is usually ignored and tricuspid interventions are mostly done in the context of other planned cardiac surgery. Isolated tricuspid reoperative procedure, especially tricuspid valve replacement (TVR) is very rare and carries a very high mortality rate. In this prospective study, clinical results of isolated TVR either through a median re-sternotomy or an antero-lateral thoracotomy with conventional cardiopulmonary bypass (CPB) have been evaluated. METHODS: Thirty patients with previous open heart surgery through median sternotomy had isolated TVR between 2004 and 2011. Operative approaches were through a median re-sternotomy in 13 patients and a right antero-lateral thoracotomy in 17 patients. RESULTS: Follow-up period is complete with a mean duration of 19.77±17.08 months. The hospital mortality rates were 46.2% (six patients) in the Median Re-sternotomy Group and 5.9% (one patient) in the Thoracotomy Group (p= 0.025). The surgical procedures lasted shorter and the postoperative drainage amounts were lower in the Thoracotomy Group (298.08±76.64min vs 246.76±47.40min, p= 0.032 and 1787.50±1399.53mL vs 903.33±692.43mL, p= 0.03 respectively). Presence of ascites in the preoperative period (p= 0.007), operative technique (median re-sternotomy) (p= 0.025), use of cross-clamp (p= 0.048), and need for inotropic support during the operation (p= 0.002) were statistically significant factors affecting the hospital mortality. The mean estimated life period was better for the Thoracotomy Group (16.7±5.03 versus 35.9±5.01 months, p= 0.044). Presence of ascites in the preoperative period was a significant risk factor for overall mortality according to Cox regression analysis. CONCLUSION: Thoracotomy for TVR in patients with previous median sternotomy is a practical and safe technique with lower mortality rates.

Successful Concomitant Revascularization in a Patient with Carotid, Coronary, and Intestinal Artery Occlusive Disease.

BACKGROUND: Chronic mesenteric ischemia and carotid stenosis frequently have coexistent coronary artery disease. Myocardial ischemia is the most common cause of morbidity and mortality following revascularization of the peripheral arteries. The optimal treatment of concurrent mesenteric, carotid, and coronary disease is unknown. CASE REPORT: We report a case of a 75-year-old man who required revascularization of the left anterior descending coronary and superior mesenteric arteries and carotid endarterectomy. After concomitant surgical revascularization, the patient remained asymptomatic during the 3-year follow-up. CONCLUSION: A good result in this case encourages us for one-stage combined surgical intervention in patients who require multisystem revascularization.

Celiac artery thrombosis and superior mesenteric artery stenoses with essential thrombocythemia: a case report.

Thrombosis of the celiac artery trunk is a rare cause of acute abdominal pain. Thrombosis of the celiac artery carries a high mortality and morbidity when the diagnoses and treatment are delayed. It is frequently associated with other cardiovascular events. The most common etiology is atherosclerosis. 20-30% of cases may have symptoms of chronic mesenteric ischemia. Main goal of the treatment is to reestablish the diminished or stopped mesenteric blood flow and to avoid end-organ ischemia. Essential thrombocythemia is a chronic myeloproliferative disorder characterized by marked increase in thrombocyte number and clinical presentation may be with thrombotic episodes, hemorrhage, or both. To our knowledge this is the first report of celiac artery thrombosis and superior mesenteric artery stenoses in a patient with essential thrombocythemia. The patient was managed successfully with surgical treatment.

Comparison of neurocognitive functions after beating-heart mitral valve replacement without aorta cross-clamping and after standard mitral valve replacement with cardioplegic arrest.

BACKGROUND: The aim of this study was to compare the postoperative long-term neurocognitive functions of patients who under-went beating-heart mitral valve replacement on cardiopulmonary bypass (CPB) without aorta cross-clamping with those of patients who underwent mitral valve replacement via the classic method. METHODS: The study group included 25 randomly selected patients who underwent beating-heart mitral valve surgery. During the same period, 25 patients were randomly selected as controls to undergo mitral valve replacement procedures via the standard ascending aorta-cannulation technique. The clinical and postoperative (2 months) neurocognitive functional data of both groups were compared. RESULTS: Neurologic deficit was observed in neither group during the postoperative period. There were no statistically significant differences between the control and the study groups with respect to Hospital Anxiety and Depression Scale (HADS) results (HADS: anxiety, P = .653; HADS: depression, P = .225), in the right hemispheric cognitive function test results (Raven's Standard Progressive Matrices [RSPM] and Line Orientation Test [LOT] tests: RSPM, P = .189), and in the left hemispheric cognitive function test results (the Ray Auditory Verbal Learning [RAVL] and Stroop Color-Word Test [SCWT] tests: SCWT 1 time, P = .300; SCWT 2 time, P = .679; SCWT 3 time, P = .336; SCWT 4 time, P = .852; SCWT 5 time, P = .416; RAVL total verbal learning, P = .167; RAVL immediate recall, P = .791; RAVL distraction trial, P = .199; RAVL retention, P = .174; RAVL delayed recall, P = .111; RAVL recognition, P = .282; SCWT 4 mistake, P = .306; SCWT 4 reform, P = .066; SCWT 5 mistake, P = .236; SCWT 5 reform, P = .301). CONCLUSIONS: The technique of mitral valve replacement with normothermic CPB without cross-clamping of the aorta may be safely used for the majority of patients requiring mitral valve replacement without causing deterioration in neurocognitive functions.

Does on-pump normothermic beating-heart valve surgery with low tidal volume ventilation protect the lungs?

BACKGROUND: Postoperative pulmonary dysfunction following cardiopulmonary bypass (CPB) usually develops secondary to the inflammatory process with contact activation, hypothermia, operative trauma, general anesthesia, atelectasis, pain, and pulmonary ischemia/reperfusion due to cross-clamping. The aim of the present study was to evaluate the effects of an on-pump, normothermic, and beating-heart technique and of low-volume ventilation on lung injury. METHODS: We compared the results for 20 patients who underwent operations with an on-pump, normothermic, and beating-heart technique of mitral valve surgery with low-volume ventilation (group 1) with the results for 23 patients who underwent their operations with an on-pump, hypothermic cardiac-arrest technique (group 2). In both groups, blood samples were collected from the right superior pulmonary vein, and inflammation and oxidative stress markers (malondialdehyde, lactic acid, platelet-activating factor, and myeloperoxidase) were studied. RESULTS: Malondialdehyde, myeloperoxidase, and lactate values were significantly lower in group 1 than in group 2 just before the termination of CPB (P < .05). We observed no differences between the 2 groups with regard to values for platelet-activating factor. CONCLUSIONS: Inflammation and oxidative stress markers were lower in the group of patients who underwent beating-heart valve surgery with low-volume ventilation. These results reflect less of an ischemic insult and lower inflammation compared with the results for the patients who underwent conventional operations.

Beating heart versus conventional mitral valve surgery.

OBJECTIVES: The present study aimed to compare the results of beating heart technique and conventional mitral valve surgery (MVS). METHODS: Three hundred and nineteen patients who underwent MVS between April 2005 and December 2006 were enrolled in the study. While 125 patients underwent beating heart MVS (group 1), the conventional approach was used for 194 patients (group 2). Of those patients who underwent beating heart MVS, 75 underwent MVS without cross-clamping the aorta. Coronary sinus retroperfusion was used during surgery in the remaining 50 patients. The right anterolateral thoracotomy was performed in nine out of the 29 patients requiring re-operation, while resternotomy was performed in 20. RESULTS: No significant differences were shown between the groups in the preoperative period in terms of the Parsonnet mortality score, Ontario mortality score, and length of intensive care stay. However, there were significant differences with respect to EuroSCORE risk score, EuroSCORE mortality, and Parsonnet risk score, and length of hospital stay according to Ontario risk scoring. It was established that the patients in group 1 had a shorter length of hospital stay [group 1: six days (range, 4-37 days); group 2: 10 days (range, 4-62 days)]. Group 1 was observed to have shorter time periods when the groups were compared regarding operative time [group 1: 130 min (range, 100-270 min); group 2: 240 min (range, 100-360 min)], cross-clamping (XCL) time [group 1: 27.5 min (range, 3-99 min); group 2: 60.5 min (range, 30-163 min)], and cardiopulmonary bypass time [group 1: 57 min (range, 22-150 min); group 2: 90 min (range, 39-388 min)]. There were also significant differences in favor of group 1 in terms of postoperative need for inotropic support [group 1: 26 patients (16%); group 2: 68 patients (35%)]. Although there were no statistically significant differences in the groups in terms of mortality rates according to the Parsonnet scoring system, with the exception of the moderate risk group, it was noted that the mortality rates in the beating heart group were lower. CONCLUSIONS: This study concluded that beating heart MVS can be performed successfully, particularly for patients at higher risk which will lead to increased morbidity and mortality in postoperative period.

Treatment of mechanical aortic valve thrombosis: fibrinolytic treatment versus surgical intervention: result of eight cases.

OBJECTIVE: : Thrombosis of mechanical heart valve prosthesis is a rare fatal complication after heart valve replacement. Although surgical intervention is the suggested treatment in many series, fibrinolytic treatment offers a good alternative. We describe eight cases with mechanical aortic valve thrombosis and compare their results after fibrinolytic treatment or redo aortic valve replacement. METHODS: : Between February 2008 and March 2009, eight patients with previous mechanical prosthetic aortic valve replacement history were admitted to our center with mechanical aortic valve thrombosis. Four patients were operated, and the remaining four patients received low-dose fibrinolytic treatment. All patients' data were collected prospectively. RESULTS: : Two of the four operated patients died. In the fibrinolytic group, all patients totally recovered, and there was no mortality or morbidity during the follow-up period. CONCLUSIONS: : We thought that fibrinolytic treatment is a feasible and effective method for thrombosed mechanical aortic valve. However, much more populated patient groups are needed for the vigorous inference.

Tricuspid valve replacement and levosimendan.

Isolated tricuspid valve replacement, which is not a common operation, is associated with poor short and long-term results, and the postoperative morbidity and mortality rates are high. The main reason for these adverse effects is the acute manifestation of chronic right heart failure. To treat right heart failure, we used levosimendan for its inotropic and vasodilatatory effects, and it does not increase the calcium overload in myocardial cells. We report two cases of tricuspid valve replacement operations performed using levosimendan. Both patients receiving levosimendan tolerated the operations well, and their postoperative courses were uneventful.

Residual postmyocardial infarction ventricular septal defect repair through right atrium with right thoracotomy on beating heart technique.

BACKGROUND AND AIM: The incidence of residual opening after repair of postmyocardial infarction ventricular septal defect (VSD) was reported to be 10% to 25%. Redo surgery with remedial sternotomy is more complex than primary surgery and is consequently associated with higher mortality and morbidity due to the myocardial and patent coronary grafts injury during pericardial dissection. METHODS: A 59-year-old female patient had coronary artery bypass grafting and closure of post myocardial infarction ventricular septal defect with patch 10 months earlier in a different cardiac center. She was admitted to the hospital for severe congestive heart failure. RESULTS: She was operated because of the residual opening after repair of post myocardial infarction ventricular septal defect. Post myocardial infarction ventricular septal defect closure was performed through the right atrium by on-pump beating heart technique via the right thoracotomy. CONCLUSIONS: Closure of post myocardial infarction ventricular septal defect with this technique offers an alternative and safe approach to repair of the residual VSD when the coronary bypass grafts are patent.

On-pump beating heart mitral valve surgery without cross-clamping the aorta.

BACKGROUND AND AIM: Cardiac reperfusion injury is a well-described complication occurring after ischemia or following cardioplegic arrest. Various strategies have been developed to prevent ischemic reperfusion injury. The aim of this study was to assess the efficacy and applicability of the on-pump beating heart mitral valve surgery without cross-clamping the aorta in order to prevent reperfusion injury. METHODS: The prospective study (between April 2005 and December 2006) included 88 consecutive patients who underwent mitral valve surgery. The operations were carried out on a beating heart using normothermic cardiopulmonary bypass without cross-clamping the aorta, therefore perfusing the heart antegradely through the aortic root. Venting the heart from the aorta and the pulmonary vein provided adequate visualization of the operative field. RESULTS: Seventy-eight patients (88.6%) underwent mitral valve replacement and 10 patients (11.3%) underwent mitral valve repair with this technique. Concomitant surgery was required in 29 patients (32.9%). Twenty-five patients (28.4%) had also undergone previous open heart surgery. Mean cardiopulmonary bypass time was 57.4 +/- 18.4 minutes. Mean duration of ventilation was 12.2 +/- 3.5 hours, mean intensive care unit stay was 1.3 +/- 1.6 days, and mean hospital stay was 6.9 +/- 4.5 days. One-year survival was 96.6% for all causes of mortality. CONCLUSIONS: In this study, we showed that on-pump beating heart operations without cross-clamping is an acceptable surgical choice for mitral valve disease. Complication rates are low and perioperative mortality is lower than that generally reported with conventional technique.

Beating heart mitral valve replacement in a patient with a previous Bentall operation.

Today, mitral valve replacement is performed under cardioplegic arrest with cross-clamping of the ascending aorta. In the case reported here, mitral valve replacement was performed with an on-pump beating heart technique without cross-clamping the aorta because of diffuse adhesion around the tube graft. A 36-year-old man had undergone a Bentall operation (aortic root replacement+coronary reimplantation) via median sternotomy because of type I aortic dissection 4 years previously in our cardiac center. He was admitted to the hospital complaining of palpitation and dyspnea on mild exertion. Transthoracic echocardiography study revealed third-degree mitral insufficiency. Mitral valve replacement was carried out through re-median sternotomy with an on-pump beating heart technique without crossclamping the aorta. On-pump beating heart mitral valve replacement without a cross-clamp offers a safe approach when excessive dissection is required to place a crossclamp on the ascending aorta.

Neurocognitive functions after beating heart mitral valve replacement without cross-clamping the aorta.

BACKGROUND AND AIM OF THE STUDY: Although neurologic outcome after cardiac surgery is well-established, neurocognitive functions after beating heart mitral valve replacement still needs to be elucidated. The aim of this study was to compare preoperative and postoperative neurocognitive functions in patients who underwent beating heart mitral valve replacement on cardiopulmonary bypass without cross-clamping the aorta. METHODS: The prospective study included 25 consecutive patients who underwent mitral valve replacement. The operations were carried out on a beating heart method using normothermic cardiopulmonary bypass without cross-clamping the aorta. All patients were evaluated preoperatively (E1) and postoperatively (at sixth day [E2] and second month [E3]) for neurocognitive functions. RESULTS: Neurologic deficit was not observed in the postoperative period. Comparison of the neurocognitive test results, between the preoperative and postoperative assessment for both hemispheric cognitive functions, demonstrated that no deterioration occurred. In the three subsets of left hemispheric cognitive function test evaluation, total verbal learning, delayed recall, and recognition, significant improvements were detected at the postoperative second month (E3) compared to the preoperative results (p = 0.005, 0.01, and 0.047, respectively). Immediate recall and retention were significantly improved within the first postoperative week (E2) when compared to the preoperative results (p = 0.05 and 0.05, respectively). CONCLUSIONS: The technique of mitral valve replacement with normothermic cardiopulmonary bypass without cross-clamping of the aorta may be safely used for majority of patients requiring mitral valve replacement without causing deterioration in neurocognitive functions.

Evaluation of hemodynamic changes in patients with mitral valve replacement using dobutamine stress echocardiography.

OBJECTIVE: The aim of this study was to investigate the response of heart to stress according to the size of the prosthetic valve in patients who had undergone mitral valve replacement by using dobutamine stress echocardiography (DSE) and to evaluate the relationship between the size of the prosthetic valve and cardiac recovery-remodeling process. METHODS: Thirty-nine patients, who had undergone mitral valve replacement were compared in terms of left ventricular diameters, systolic functions and cardiac mass indexes in order to investigate the effect of the mechanical valve size on postoperative cardiac remodeling in this longitudinal study. They were divided into three groups according to their valve size: Group 1 (valve size<29 mm, n=11), Group 2 (valve size=29 mm, n=11) and Group 3 (valve size>29 mm, n=17). Statistical analysis was performed using Chi-square and one-way ANOVA tests to determine the statistical differences between the groups. The repeated measurements of two-way ANOVA test was used to analyze effects during long-term follow-up. RESULTS: Only Group 1 patients achieved a significant decrease in terms of left ventricular mass index and end-diastolic diameter (138.3+/-29.7 g/m2 vs 86.6+/-15.6 g/m2 and 5.1+/-0.5 cm vs. 4.4+/-0.4 cm, p<0.05). Group 3 patients' left ventricular ejection fraction become worse after the operation (64.0+/-5.6% vs. 55.9+/-6.5%, p<0.05). Maximum and mean pressure gradients across the mitral prosthesis as well as pulmonary artery pressure were significantly increased in all groups during DSE. Maximum gradients increased from 14.2+/-4.6 to 20.7+/-7.5 mmHg in Group 1 (p<0.05), 11.6+/-4.7 to 16.2+/-6.8 mmHg in Group 2 (p<0.05), and 10.6+/-3.1 to 20.8+/-12.7 mmHg in Group 3 (p<0.05). Isovolumic relaxation time decreased in all groups following the dobutamine infusion, as expected, but this decline was not significant in Group 3. CONCLUSION: A worsening in left ventricular systolic function was observed in large- sized valve prosthesis group. Only the patients who had undergone MVR with small-sized valve prosthesis achieved a decrease in cardiac mass index and preservation of the systolic function. The echocardiographically determined differences and mass index that appeared after the operation may point out that, the effect of the operation on cardiac remodeling can be related with the ventricular size.

The gender differences in the relaxation to levosimendan of human internal mammary artery.

PURPOSE: The mechanism of the vasorelaxation to levosimendan varies depending on the vascular bed and species studied. Here, we examined the vasorelaxation to levosimendan as well as its modification by various potassium channel antagonists in human internal mammary artery (IMA) obtained from male and female patients. METHODS: IMA grafts were supplied from 27 male and 19 age-matched female patients undergoing coronary bypass operation. The contraction to noradrenaline and relaxation to levosimendan were studied in IMA rings obtained from both gender. The relaxations to levosimendan were also assessed in the presence of glibenclamide (10 microM), an adenosine triphosphate-sensitive potassium channel (K(ATP)) blocker, or charybdotoxin (100 nM), a calcium-activated potassium channel (K(Ca)) blocker, or 4-aminopyridine(1 mM), a voltage-sensitive potassium channel (K(v)) inhibitor. RESULTS: Concentration-response curves to noradrenaline were not different in IMA rings from either gender. Pretreatment with levosimendan (3 x 10(-7) M) slightly modified the contractions to noradrenaline in both gender. Levosimendan (10(-9)-10(-5) M) produced concentration-dependent relaxation in IMA rings, contracted by noradrenaline (5 x 10(-6) M), from males and females. The vasodilatory effects of levosimendan were more pronounced in the arteries from males (83%) than females (69%), in term of the maximal relaxation (E (max)). Charybdotoxin and glibenclamide significantly inhibited the relaxation to levosimendan in the arteries from males but not in those of females. CONCLUSIONS: The vasodilating efficacy of levosimendan and its relaxation mechanism differs between the arteries from males and females, which may have clinical consequences in the treatment of heart failure.

Aortic valve replacement with on-pump beating heart technique.

BACKGROUND: The aim of this study was to assess the efficacy and applicability of on-pump beating heart aortic valve replacement with retrograde coronary sinus (CS) warm blood perfusion. METHODS: The prospective study included 14 consecutive patients who underwent aortic valve replacement with mechanical prosthesis using retrograde CS perfusion. The operative variables and early outcome of this procedure are presented. RESULTS: Retrograde CS perfusion and venting the heart from the pulmonary vein provided good visualization of the operative field and performance of the operations without any difficulty. Partial oxygen pressures of CS perfusion blood and the returning blood from the coronary ostia were 288.5 +/- 34.4 and 39.6 +/- 4.6 mmHg, respectively. Postoperative peak creatine kinase-MB and troponin T values were mean 77.0 +/- 63.6 IU/L and mean 0.8 +/- 0.7 ng/mL, respectively. No mortality or major complication was observed and all the patients were discharged from the hospital in good condition. CONCLUSIONS: On-pump beating heart aortic valve replacement with retrograde CS warm blood perfusion is a good surgical option, and has the advantage of maintaining physiologic condition of the heart throughout the procedure.