Comparison of minimal invasive extracorporeal circulation versus standard cardiopulmonary bypass systems on coronary artery bypass surgery.

Background: In this study, we shared our experience with the minimal invasive extracorporeal circulation system for coronary artery bypass grafting patients. Methods: A total of 163 patients were included in the retrospective study, with 83 patients (63 males, 20 females; mean age: 61.9±8.9 years; range, 35 to 81 years) undergoing coronary artery bypass grafting with minimal invasive extracorporeal circulation and 80 patients (65 males, 15 females; mean age: 60.5±8.8 years; range, 43 to 82 years) undergoing coronary artery bypass grafting with conventional cardiopulmonary bypass between July 2021 and April 2023. Elective coronary bypass performed by same surgical team were included in the study. Mortality, major adverse cardiac and cerebrovascular event, hospital stays and transfusion requirements were evaluated. Results: There were no significant differences in sex distribution, age, comorbidities, and blood values between the two groups. Intraoperatively, the minimal invasive extracorporeal circulation group had a slightly higher number of distal anastomoses and comparable times for aortic cross-clamp and cardiopulmonary bypass. Postoperative outcomes such as tamponade, bleeding, atrial fibrillation, left ventricular ejection fraction improvement or reduction, and postoperative drainage were similar between the two groups. However, the minimal invasive extracorporeal circulation group had fewer transfusions of packed red blood cells and fresh frozen plasma and a shorter length of stay in the intensive care unit. Conclusion: The minimal invasive extracorporeal circulation system effectively preserves blood, works with lower activated clotting time values without additional complications in coronary artery bypass grafting, and could present a better option for patients with anemia or patients with a relatively high risk for high-dose heparinization.

Outcomes of conservative management in patients with nutcracker syndrome.

OBJECTIVE: This study aims to evaluate outcomes in nutcracker syndrome patients with tolerable symptoms and treated conservatively without invasive interventions. METHODS: This prospective study included patients treated conservatively. Promoting weight gain, the endpoint of the study was spontaneous resolution of symptoms. RESULTS: Sixteen patients (75% female and mean age 24.4 ± 3.5 years) underwent conservative management. Over a mean follow-up of 27.3 months [13-42, interquartile range (IQR)], the diameter ratio (5.5 [5-6.5, IQR] vs 4.3 [4.1-6], p = NS), the peak velocity ratio (6 [5-7, IQR] vs 4.8 [4.8-5.8], p = NS), beak angle (27° [24-30, IQR] vs 29° [24-32]; p = NS), and aortomesenteric angle (26° [23-29, IQR] vs 28° [24-30]; p = NS) exhibited no statistically significant changes. Complete resolution and improvement of symptoms were 28.5% and 31.4%, respectively, while 68.5% remained unchanged. CONCLUSIONS: This study shows that a conservative approach contributes to the spontaneous improvement or complete resolution in young adult patients with mild symptoms.

Treatment of Nutcracker Syndrome with Left Renal Vein Transposition and Endovascular Stenting.

BACKGROUND: Nutcracker syndrome is a rare condition that occurs as a result of the entrapment of the left renal vein (LRV) between the aorta and the superior mesenteric artery. It is typically associated with symptoms such as left flank pain, hematuria, proteinuria, and pelvic congestion. The current treatment approach may be conservative in the presence of tolerable symptoms, and surgical or hybrid and stenting procedures in the order of priority in the presence of intolerable symptoms. The aim of this study is to review our experiences to evaluate the results of both methods in this series in which we have a greater tendency toward surgery instead of stenting. METHODS: The clinical data of consecutive patients with nutcracker syndrome who underwent LRV transposition and LRV stenting between July 2019 and October 2023 were retrospectively reviewed. The patients were divided into 2 groups based on the methods of treatment: surgical and stenting. For procedure selection, LRV transposition was primarily recommended, with stenting offered to those who declined. Primary end points were morbidity and mortality. Secondary end points included late complications, patency, freedom from reintervention, and resolution of symptoms. Standard basic statistics and survival analysis methods were employed. RESULTS: Nineteen patients with nutcracker syndrome (female: 100%) were treated with LRV stentings (n = 5) and LRV transposition (n = 14). The mean age was 24 (20-27, interquartile range [IQR]) years. The mean follow-up was 23 (9-32, IQR) months. There were no major complications and mortality after both procedures. The most frequent sign and symptom associated with LRV entrapment were left flank pain 100% (n = 19), proteinuria 88% (n = 15), and hematuria 47% (n = 9). The mean peak velocity ratio on Doppler ultrasound was 6.13 (6-6.44, IQR). Aortomesenteric angle, beak angle (beak sign), and mean diameter ratio on computed tomography were 26° (22.6-28.5, IQR), 25° (23.9-28, IQR), and 5.3 (5-6, IQR), respectively. Venous pressure measurements were only used to confirm the diagnosis in 5 patients in the stenting group. The measured renocaval gradient was 4 (3.9-4.4, IQR) mm Hg. After both procedures, the classical symptoms, including left flank pain, proteinuria, and hematuria, resolved in 89.5% (n = 17), 57.8% (n = 11), and 82.3% (n = 15) of the cases, respectively. A total of 4 patients required reintervention, 3 patients after LRV transposition (occlusion, n = 2; stenosis, n = 1), and 1 patient after stenting (occlusion, n = 1). The 1-year and 3-year primary patency for the 19 patients was 87% and 80%, respectively. Three-year primary-assisted patency was 100%. Similarly, the 1-year and 3-year freedom from reintervention rate was 83% and 72%, respectively. Additionally, the 1-year and 3-year primary patency for the surgical group was 91% and 81%, respectively, and the 1-year and 3-year primary patency for the stenting group was 75%. CONCLUSIONS: Nutcracker syndrome should be kept in mind in cases where flank pain and hematuria cannot be associated with kidney diseases. Radiographic evidence must be accompanied by serious symptoms to initiate the treatment of nutcracker syndrome with LRV transposition and endovascular stenting procedures. Both procedures, along with their respective advantages and disadvantages, can be preferred as primary treatments for nutcracker syndrome. Our study demonstrates that both procedures can be safely and effectively performed, yielding good outcomes.

Reverse-U Aortotomy (Kirali Incision) for Aortic Valvular Interventions.

BACKGROUND: Surgical incisional approach to the ascending aorta is the main strategic step during valvular and/or subvalvular aortic interventions. Classic aortotomy incisions (transverse or oblique) can be challenging and can cause suboptimal exposure of the aortic root especially for the patients with small aortic annulus or for redo coronary artery bypass patients with patent proximal grafts interposed to the ascending aorta. METHODS: The Kirali incision was used in 91 patients (including 13 reoperations) who underwent an aortic intervention for valvular and subvalvular pathologies. Aortic root was exposed by forming inverted "U" shape incision starting from approximately 3 cm above the right coronary ostium toward the center of the noncoronary annulus and the top of the left-right commissure like a tongue. RESULTS: The aortic valve was replaced with a mechanical prosthesis in 45 patients and with a bioprosthesis in 39 patients including 14 sutureless and 16 stentless prostheses. A total of 29 patients received a concomitant procedure per the following: coronary artery bypass grafting on 8 patients and left ventricular assist device on 7 patients. There was no any problem related to aortotomy incision technique such as bleeding, rupture, dehiscence, or laceration perioperatively. There was no complication related to the procedure during 5-year follow-up. CONCLUSION: This new aortotomy incision technique is a safe procedure that provides good exposure for all kinds of aortic valve interventions and protects grafts and can facilitate aortic root enlargement or aortoplasty easily. This incision has the potential to be an alternative to traditional techniques.

Long-Term Results of Thoracofemoral Bypass in the Initial Treatment of Juxtarenal Total Aortic Occlusion.

BACKGROUND: Thoracofemoral bypass has been applied mostly secondary to previous procedures in the treatment of aortoiliac occlusive disease. However, its application as an initial treatment is less common, and long-term outcomes remain uncertain. The aim of this analysis was to review the 16-year experience and long-term outcomes of 31 consecutive patients who underwent thoracofemoral bypass as the primary procedure. METHODS: All patients who underwent thoracofemoral bypass for severe aortoiliac occlusive disease between 2005 and 2021 were retrospectively analyzed. The occlusion and calcified plaques of the abdominal aorta at the renal level were common characteristics of all patients. The patients were divided into 2 groups: severe claudication group (Rutherford III group) and chronic limb-threatening ischemia group (Rutherford IV-V). Chi-square test or Fisher's exact test was used to compare categorical variables between the groups, and t-test or Mann-Whitney U-tests were used to compare continuous variables according to their distributions. The Kaplan-Meier curve was used to depict the time-to-event data. RESULTS: Thirty-one patients [age: 62 (56-67.5); male: 87%] underwent thoracofemoral bypass. Among the 31 patients, 21 (67.7%) belonged to the severe claudication group (Rutherford III), while 10 (32.3%) were in the chronic limb-threatening ischemia (Rutherford IV-V). Twenty-two patients (83.8%) remained asymptomatic after thoracofemoral bypass. The mean follow-up duration was 79 ± 32 months. The 30-day mortality rate was 3.2% (n = 1). Major complications were observed in 9.6% of patients (n = 3; respiratory: 6.4%, retroperitoneal hematoma: 3.2%). No significant difference was found between the claudication and chronic limb-threatening ischemia groups regarding major complications (3.2% vs. 6.4%, P = NS). Minor complications occurred in 41.9% of patients, including pleural effusion 9.6% (n = 3), acute kidney injury 9.6% (n = 3), gastrointestinal bleeding 3.2% (n = 1), paralytic ileus 6.4% (n = 2), and superficial skin infection 12.9% (n = 4). The rate of postoperative superficial skin infection was higher in the chronic limb-threatening ischemia group compared to the claudication group (4 [40%] vs. 0 [0%], P: 0.007). The univariable Cox regression analysis revealed that hypertension and diabetes mellitus were not related to primary patency of the thoracofemoral bypass graft. The 5-year Kaplan-Meier estimated primary patency for the entire study was 96% ± 7% (95% confidence interval [CI]: 88.6-100), and the secondary patency was 96.3% ± 6% (95% CI: 89.4-100). The 5-year Kaplan-Meier estimated survival rate after thoracofemoral bypass was 93.4% ± 3 (95% CI: 91-100). CONCLUSIONS: We demonstrated in this study that thoracofemoral bypass can yield good outcomes when preferred as the initial treatment in selected patients with juxtarenal total aortic occlusion. Despite being a complex surgical technique, thoracofemoral bypass has shown to have safe, acceptable mortality and morbidity rates, as well as excellent long-term follow-up results in selected patients.

Transcatheter Closure or Surgery for Symptomatic Paravalvular Leaks: The Multicenter KISS Registry.

BACKGROUND: The optimal treatment of symptomatic paravalvular leak (PVL) remains controversial between transcatheter closure (TC) and surgery. This large-scale study aimed to retrospectively evaluate the long-term outcomes of the patients who underwent reoperation or TC of PVLs. METHODS AND RESULTS: A total of 335 (men, 209 [62.4%]; mean age, 58.15±12.77 years) patients who underwent treatment of PVL at 3 tertiary centers between January 2002 and December 2021 were included. Echocardiographic features, procedure details, and in-hospital or long-term outcomes were assessed. The primary end point was defined as the all-cause death during follow-up. The regression models were adjusted by applying the inverse probability weighted approach to reduce treatment selection bias. The initial management strategy was TC in 171 (51%) patients and surgery in 164 (49%) cases. Three hundred cases (89.6%) had mitral PVL, and 35 (10.4%) had aortic PVL. The mean left ventricular ejection fraction was 52.03±10.79%. Technical (78.9 versus 76.2%; P=0.549) and procedural success (73.7 versus 65.2%; P=0.093) were similar between both groups. In both univariate and multivariable logistic regression analysis, the in-hospital mortality rate in the overall population was significantly higher (15.9 versus 4.7%) in the surgery group compared with the TC group (unadjusted odds ratio, 3.13 [95% CI, 1.75-5.88]; P=0.001; and adjusted odds ratio (inverse probability-weighted), 4.55 [95% CI, 2.27-10.0]; P<0.001). However, the long-term mortality rate in the overall population did not differ between the surgery group and the TC group (unadjusted hazard ratio [HR], 0.86 [95% CI, 0.59-1.25]; P=0.435; and adjusted HR (inverse probability-weighted), 1.11 [95% CI, 0.67-1.81]; P=0.679). CONCLUSIONS: The current data suggest that percutaneous closure of PVL was associated with lower early and comparable long-term mortality rates compared with surgery.

Long-term experience of the modified David V re-implantation technique for valve-sparing aortic root replacement.

OBJECTIVE: The modified David V technique is one of the valve-sparing aortic root replacement (V-SARR) techniques, which is an alternative to traditional composite valve graft root replacement techniques. We aimed to analyse our long-term experience with the modified David V re-implantation technique for the treatment of aortic root aneurysm and significant aortic valve insufficiency. METHODS: From March 2009 to November 2021 the modified David V re-implantation technique, one of the V-SARR techniques, was performed on 48 patients in our centre. The results were analysed retrospectively. Two different-sized grafts were used in all patients. The grafts used in the proximal position were larger than the distal grafts. We performed both intra-operative and post-procedural transoesophageal echocardiography on each patient. All patients were followed by means of transthoracic echocardiography. The mean follow-up period was 5.7 ± 3.1 years. RESULTS: The mean age of this cohort was 56.3 ± 14.3 years (24-79) and the majority were men (75%). The mean aortic root diameter was 5.1 ± 0.6 cm. The mean diameter for the assending aorta was 5.4 ± 2.1 cm. The in-hospital mortality rate was 4.2% (n = 2). One patient needed aortic valve replacement in the early postoperative period. Two (4.2%) patients died in the early postoperative period and four (8.3%) died in the late postoperative period. Overall survival was 91 ± 4 and 86 ± 5% at one and five years, respectively. Aortic valve insufficiency was at moderate levels postoperatively. Freedom from moderate to severe residual aortic insufficiency was 89.6% at 10 years. None of the patients needed late re-operation of the aortic valve postoperatively. Freedom from valve re-operation was 100% at the end of the follow up. CONCLUSION: Our study shows that the David V technique is associated with excellent long-term durability, a remarkably low rate of valve-related complications, and it protects the re-implanted native aortic valve from a second operation. Additionally this technique could be safely implemented in patients with a bicuspid aortic valve and acute type A aortic dissection without leaflet deformity.

Surgical experience in adults with Ebstein's anomaly: Long-term results.

OBJECTIVE: The aim of this study was to review late results of the surgical treatment of Ebstein's anomaly with reconstruction and replacement in adults. METHODS: Medical records of 28 consecutive patients operated on between 1991 and 2014 were reviewed retrospectively. Surgical repair was performed in 19 (67.9%) patients (Hardy: two, Danielson: three, modified Danielson: six, Carpentier: three, Kay annuloplasty reinforced with ring: two), whereas tricuspid valve replacement was performed in nine patients (32.1%). Primary long-term outcomes consisted of right ventricular function, survival and freedom from re-operation. We evaluated the additional impacts of residual tricuspid insufficiency and type of surgery on survival. RESULTS: In-hospital mortality rate was 7.1% (n = 2) due to low cardiac output status and sepsis. Patients showed a significant postoperative decrease in tricuspid regurgitation (p < 0.001), right atrial size (p < 0.001) and pulmonary hypertension (p = 0.002). The mean follow-up time was 140 ± 71.4 months, with a median of 126 months (105 - 192). Late mortality occurred in two patients and there was no significant difference in terms of survival based on residual tricuspid insufficiency (p = 0.57) and type of surgery (p = 0.094). Overall survival rates were 89.3, 85.4, 85.4 and 68.3% at five, 10, 15 and 20 years, respectively. CONCLUSIONS: Although complex leaflet reconstruction techniques have evolved to achieve a more physiological and durable repair, both approaches can be performed safely on specific patients and can be alternated, with acceptable rates of survival and re-operation.

Thrombolysis or Surgery in Patients With Obstructive Mechanical Valve Thrombosis: The Multicenter HATTUSHA Study.

BACKGROUND: Prosthetic valve thrombosis (PVT) is one of the life-threatening complications of prosthetic heart valve replacement. Due to the lack of randomized controlled trials, the optimal treatment of PVT remains controversial between thrombolytic therapy (TT) and surgery. OBJECTIVES: This study aimed to prospectively evaluate the outcomes of TT and surgery as the first-line treatment strategy in patients with obstructive PVT. METHODS: A total of 158 obstructive PVT patients (women: 103 [65.2%]; median age 49 years [IQR: 39-60 years]) were enrolled in this multicenter observational prospective study. TT was performed using slow (6 hours) and/or ultraslow (25 hours) infusion of low-dose tissue plasminogen activator (t-PA) (25 mg) mostly in repeated sessions. The primary endpoint of the study was 3-month mortality following TT or surgery. RESULTS: The initial management strategy was TT in 83 (52.5%) patients and surgery in 75 (47.5%) cases. The success rate of TT was 90.4% with a median t-PA dose of 59 mg (IQR: 37.5-100 mg). The incidences of outcomes in surgery and TT groups were as follows: minor complications (29 [38.7%] and 7 [8.4%], respectively), major complications (31 [41.3%] and 5 [6%], respectively), and the 3-month mortality rate (14 [18.7%] and 2 [2.4%], respectively). CONCLUSIONS: Low-dose and slow/ultraslow infusion of t-PA were associated with low complications and mortality and high success rates and should be considered as a viable treatment in patients with obstructive PVT.

The analysis of unplanned readmissions after left ventricular assist device implantation as bridge-to-transplant.

BACKGROUND: In this study, we aimed to investigate frequency, patterns, etiologies, and costs of unplanned readmissions after left ventricular assist device implantation. METHODS: Between April 2012 and September 2016, 99 unplanned readmissions of a total of 50 consecutive bridge-to-transplant patients (45 males, 5 females; mean age 46.9±10.3 years; range, 19 to 67 years) who were successfully discharged after left ventricular assist device implantation were retrospectively analyzed. Patient demographic data, hemodynamic measurements before implantation, and readmissions after discharge were recorded. Hospitalizations due to major problems which were unable to be managed in routine outpatient clinic were accepted as unplanned readmissions. Survival analysis was performed. RESULTS: The readmission rate was 1.7 per year after discharge. Survival of patients who were readmitted within the first 90 days was found to be significantly lower than those without early readmission. The most common reasons of readmissions during follow-up were major infection (23.2%), neurological dysfunction (22.2%), cardiac causes (12.1%), bleeding (11.1%), and device malfunction (10.1%). Neurological dysfunctions (82,005 USD) and device malfunctions (73,300 USD) caused the highest economic burden. CONCLUSION: Among patients with a left ventricular assist device, hospital readmissions are common. Development of preventive strategies as well as effective treatment methods focused on longterm adverse events is critical to reduce the frequency and costs of hospital readmissions.

Transition from Conventional Technique to Less Invasive Approach in Left Ventricular Assist Device Implantations.

Surgical treatments for heart failure patients are being increasingly performed every year. While experiences in this field are increasing, transition to alternative surgical approaches to minimize incisions is gaining popularity. However, there are clinics that still avoid performing these techniques. In the current study, we aim to present our experiences in transitioning to a minimally invasive technique by comparing two groups. One group was operated with a minimally invasive technique that has been performed in the learning curve period, while the second was operated with a familiar and standard technique. One hundred twenty patients who were implanted with left ventricular assist devices (LVADs) from April 2015 to January 2019 were retrospectively analyzed. The first 30 LVAD-implanted patients via less invasive approach (since April 2017) were included in group 1, and the last 30 isolated LVAD implanted patients via standard full sternotomy were included in group 2. Early clinical outcomes were compared between these two groups. There were no significant differences between two groups in terms of demographic features and preoperative statuses. Group 1 had significantly lesser mortality rates, cardiopulmonary bypass times, drainages, and blood products. Hospital stays had no significant difference between the groups, while extubation times and ICU stays were significantly lesser in group 1. Left ventricular assist device implantation through thoracotomy and ministernotomy is as feasible as that done through the conventional full sternotomy technique. In this group of patients with a high risk of bleeding, besides providing less hemorrhage, we believe that the surgical procedure was not more difficult than the conventional method.

Regenerating a ventricular cavity during left ventricular assist device implantation.

Ten months after an ineffective percutaneous coronary stent placement, a 53-year-old patient was rehospitalized with NYHA functional class IV congestive heart failure, ischemic heart disease and left ventricular aneurysm. Echocardiography revealed thrombus formation in the left ventricle with apical aneurysm. Even though left ventricular assist device (LVAD) implantation improves quality of patients' lives with an increase of its overall use, it becomes more complicated in the presence of ventricular thrombus. We decided to perform ventricular reconstruction with thrombus extraction concomitant to HeartMate 3™ LVAD implantation. The patient was recovered uneventfully, and discharged on postoperative day 14. This report shares the patient's case and the surgical procedure.

Fluid inside driveline after left ventricular assist device implantation: A rare case.

In this article, we present our diagnostic and therapeutic approach in a rare case in whom fluid inside the driveline developed following left ventricular assist device implantation.

Intra-aortic balloon pump experience: a single center study comparing with and without sheath insertion.

Introduction: The mechanical circulation support used in treatment of low cardiac output at most is the intra-aortic balloon pump (IABP). Its usage fields are the complications occurring due to ischemic heart disease, disrupted left ventricle function, and the low cardiac output syndrome occurring during coronary artery by-pass surgery. Methods: During 28 years from 1985 to 2013, IABP support has been implemented to 3135 patients in our cardiac surgery operating theater and intensive care unit. The mean age of the patients was 61.4 ± 13.2 years (16-82). 2506 patients (80%) were the ones whom the cardiac surgery has been implemented. IABP support has been provided for 629 (20%) patients for medical treatment. We utilized IABP most frequently in coronary artery patients (70%). The first choice for placing the balloon catheter is the femoral artery in 3093 cases (98.7%). Results: The most frequently observed balloon complication was the lower extremity ischemia in 383 cases (12.2%).The leg ischemia was statistically significantly more frequent in patients with sheath (P=0.004). The extremity ischemia has developed in 4 of 12 patients with balloon placed from upper extremity. The local bleeding and balloon rupture were more frequent in patients whom the balloon has been placed without sheath. The mortality due to IABP has occurred in only 5 patients. Conclusion: Despite increase in IABP usage frequency rapidly, the complications due to catheter are still seen. We believe that the leg ischemia that is the most frequently seen complication can be prevented via IABP use without sheath.

The role of genetics in coronary artery bypass surgery patients under 30 years of age.

AIM: We undertook genetic assessment of coronary artery disease (CAD) in 20 patients aged 30 years or less undergoing coronary artery bypass grafting (CABG) surgery, to investigate the prognostic value of pre-defined genes. METHODS: Twenty patients, who underwent CABG surgery between December 2001 and May 2013, were retrospectively analysed to find out the role their genetic make-up played in their disease. We used three genetic diagnostic tests, the plasminogen activator inhibitor (PAI) -1 gene, the A1/A2 polymorphism of glycoprotein IIIa (GpIIIa) gene, and common polymorphisms of the methylenetetrahydrofolate reductase (MTHFR) gene. RESULTS: The mean age of patients was 26.35 ± 3.51 (19-30) years, and 90% were male (n = 18). One patient had diabetes, three had hypertension, 11 (55%) had dyslipidaemia and 16 (80%) were smokers. Eight of the patients (40%) had left ventricular ejection fraction (LVEF) < 50%, and functional capacity was poor in only two (10%) patients (NYHA III-IV). Follow up was completed in all patients (100%). We found five homozygous and 11 heterozygous mutations in the MTHFR gene, which predisposes individuals to coronary artery disease or deep-vein thrombosis. Eight patients were found to have a GpIIIa gene polymorphism, which is associated with increased risk of myocardial infarction (MI). Fifteen patients had a polymorphism in the promoter region of the PAI-1 gene, which is a major inhibitor of the fibrinolytic system. CONCLUSION: MTHFR C677T polymorphism, and GpIIIa and PAI-1 genes are risk factors for CAD. In young patients, genetic studies promise to revolutionise early diagnosis, treatment and prevention of CAD and MI.

Surgery for Aortic Root Abscess: A 15-Year Experience.

Aortic root abscess is the most severe sequela of infective endocarditis, and its surgical management is a complicated procedure because of the high risk of morbidity and death. Twenty-seven patients were included in this 15-year retrospective study: 21 (77.8%) with native- and 6 (22.2%) with prosthetic-valve endocarditis. The surgical reconstruction of the aortic root consisted of aortic valve replacement in 19 patients (70.4%) with (11) or without (8) a pericardial patch, or total aortic root replacement in 7 patients (25.9%); 5 of the 27 (18.5%) underwent the modified Bentall procedure with the flanged conduit. Only one patient (3.7%) underwent subaortic pericardial patch reconstruction without valve replacement. A total of 7 patients (25.9%) underwent reoperation: 6 with prior valve surgery, and 1 with prior isolated sinus of Valsalva repair. The mean follow-up period was 6.8 ± 3.7 years. There were 6 (22.2%) in-hospital deaths, 3 (11.1%) of which were perioperative, among patients who underwent emergent surgery. Five patients (23.8%) died during follow-up, and the overall survival rates at 1, 5, and 10 years were 70.3% ± 5.8%, 62.9% ± 6.4%, and 59.2% ± 7.2%, respectively. Two of 21 patients (9.5%) underwent reoperation because of paravalvular leakage and early recurrence of infection during follow-up. After complete resection of the perianular abscess, replacement of the aortic root can be implemented for reconstruction of the aortic root, with or without left ventricular outflow tract injuries. Replacing the aortic root with a flanged composite graft might provide the best anatomic fit.

Effect of ejection fraction on left ventricular remodeling in aortic insufficiency.

BACKGROUND: Due to ventricular compensatory mechanisms, patients with severe aortic regurgitation are generally asymptomatic. Severe left ventricular dysfunction develops annually in 20% of non-operated cases, and the prognosis in those cases is poor. Although surgery is recommend in patients with left ventricular dysfunction, surgeons are wary. We investigated the changes in ventricular and effort capacity after surgery in patients with normal and abnormal left ventricular function. METHODS: We retrospectively examined the data of patients with aortic regurgitation who underwent aortic valve replacement in our clinic between 1993 and 2013. Those who had previous cardiac surgery, chemotherapy, radiotherapy, renal dysfunction, diabetes mellitus, or preoperative arrhythmias were excluded. The 113 patients were divided into 2 groups according to ejection fraction. RESULTS: In patients with ejection fraction <50%, interventricular septal thickness, posterior wall thickness, and left ventricular mass were significantly greater than in the ejection fraction ≥50% group (p < 0.01). No significant differences in intensive care unit stay and hospitalization were determined. No mortality was observed. Ejection fraction and effort capacity increased significantly after aortic valve replacement in both groups, and interventricular septal thickness, posterior wall thickness, and left ventricular mass decreased in both groups. CONCLUSIONS: Significant left ventricular functional improvements can be achieved after aortic valve replacement in patients with severe aortic regurgitation who develop left ventricular dysfunction. Despite the reported higher surgical mortality in this patient group, surgical treatment offers a survival benefit. We recommend surgical treatment in patients with severe aortic regurgitation who develop left ventricular dysfunction.

Thermoreactive nitinol clips: Propensity score comparison with Robicsek technique.

OBJECTIVE: To compare the use of thermoreactive nitinol clips with the classic Robicsek technique for treatment of sternal dehiscence after cardiac surgery. METHODS: Eighty-two (2.3%) of 3564 open heart surgery patients underwent reoperation for sternal dehiscence between October 2011 and 2012. Prospectively collected data from 26 (31%) consecutive patients who underwent reoperation using thermoreactive nitinol clips were compared with those of a retrospective cohort of 42 (51.2%) who were treated with the classic Robicsek technique. To overcome baseline and operative variations, we constructed a propensity model using logistic regression. RESULTS: Overall mortality occurred in 3 (5%) patients and a second revision was performed in 2 (7.7%) in the nitinol clip group and 2 (6.3%) in the control group (p > 0.05). Postoperative results were similar except for the mean time of operation which was significantly shorter in the nitinol clip group, and patients in this group required substernal dissection slightly less frequently than those in the control group. CONCLUSIONS: Thermoreactive nitinol clips allow the surgeon to perform a rapid and less challenging technique for sternal reoperations, without additional complications. Using this technique in an identical group with a finite sample size, we accomplished similar early results to those of the classic Robicsek technique.

Cardiac cystic echinococcosis: Report of three cases.

We present a retrospective analysis of three cases of cardiac hydatidosis, who underwent surgery between 2010 and 2012. Two patients had a lesion in the interventricular septum, whereas one patient had the lesion in apicoinferior wall of LV. The diagnosis was made by echocardiography, but magnetic resonance imaging was utilized to assess cyst activity and extend of disease. All patients were placed on cardiopulmonary bypass. No postoperative complication or death occurred. The patients discharged uneventfully and all of them were free from hydatid disease at two years follow-up. We concluded that cardiac hydatid cysts should be removed surgically regardless of their location or extent, even in asymptomatic patients.

A case report on concomitant coronary artery bypass operation and renal transplantation.

Renal transplantation is successfully implemented in patients undergoing coronary bypass surgery. We performed concomitant coronary bypass surgery and renal transplantation in a patient found to have a left main coronary artery lesion after coronary angiography, which was performed in our clinic during preoperative evaluation of renal transplantation. We suggest the application of coronary-artery bypass grafting (CABG) or stent implantation 2 months after renal transplantation in asymptomatic patients with coronary artery disease. But, if severe coronary artery disease is detected in symptomatic patients, we suggest the concurrent application CABG and renal transplantation.