Raising the bar to ultradisciplinary collaborations in management of chronic thromboembolic pulmonary hypertension.

Chronic thromboembolic pulmonary hypertension is an underdiagnosed and potentially fatal subgroup of pulmonary hypertension, if left untreated. Clinical signs include exertional dyspnea and non-specific symptoms. Diagnosis requires multimodality imaging and heart catheterization. Pulmonary endarterectomy, an open heart surgery, is the gold standard treatment of choice in selected patients in specialized centers. Targeted medical therapy and balloon pulmonary angioplasty can be effective in high-risk patients with significant comorbidities, distal pulmonary vascular obstructions, or recurrent/persistent pulmonary hypertension after pulmonary endarterectomy. Currently, there is a limited number of data regarding novel coronavirus-2019 infection in patients with chronic thromboembolic pulmonary hypertension and the changing spectrum of the disease during the pandemic. Challenging times during this outbreak due to healthcare crisis and relatively higher case-fatality rates require convergence; that is an ultradisciplinary collaboration, which crosses disciplinary and sectorial boundaries to develop integrated knowledge and new paradigms. Management strategies for the "new normal" such as virtual care, preparedness for further threats, redesigned standards and working conditions, reevaluation of specific recommendations, and online collaborations for optimal decisions for chronic thromboembolic pulmonary hypertension patients may change the poor outcomes.

The Largest Reported Giant Ascending Aortic Aneurysm Presented with Superior Vena Cava Syndrome.

Giant ascending aortic aneurysm is a rare condition. In this paper, we present an uncommon case of giant ascending aortic aneurysm with a maximal diameter of 14 cm in a 77-year-old woman presenting with unusual symptoms. The patient underwent a successful surgery involving ascending aortic replacement, and was discharged without any complication. After discharge, she was followed regularly and no major problem was observed in her control visits. To the best of our knowledge, our case is the largest ascending aortic aneurysm reported to date in the existing literature.

The largest reported giant ascending aortic aneurysm presented with superior vena cava syndrome

Abstract Giant ascending aortic aneurysm is a rare condition. In this paper, we present an uncommon case of giant ascending aortic aneurysm with a maximal diameter of 14 cm in a 77-year-old woman presenting with unusual symptoms. The patient underwent a successful surgery involving ascending aortic replacement, and was discharged without any complication. After discharge, she was followed regularly and no major problem was observed in her control visits. To the best of our knowledge, our case is the largest ascending aortic aneurysm reported to date in the existing literature.

A comparison of early clinical outcomes of off-pump and on-pump coronary artery bypass grafting surgery in elderly patients.

BACKGROUND: The reply of question of "which coronary artery bypass grafting (CABG) technique is superior in elderly patients, off-pump or on-pump CABG surgery?" is controversial. We aimed to compare the early clinical outcomes in elderly patients undergoing off-pump and on-pump CABG. METHODS: From January 2009 to January 2015, 344 elderly patients (aged 70 or older) underwent off-pump (n = 137) or on-pump (n = 207) CABG. Patients' medical records were retrospectively reviewed, and their baseline preoperative characteristics, operative data and postoperative outcomes were analyzed, thereby a comparison of early outcomes between off-pump and on-pump patients was performed. RESULTS: Mean age of patients was 74.4 ± 3.8 years. Both groups were statistically similar in terms of baseline preoperative characteristics. Number of distal bypass was significantly lower in off-pump group than in on-pump group. Postoperative length of intensive care unit and hospital stay were similar between two groups. Amounts of transfused blood products were significantly lower in off-pump CABG group. There were no significant differences in terms of postoperative complications and mortality between two groups. CONCLUSIONS: Our results did not reveal a significant benefit of either surgical technique with respect to early-term clinical outcomes in elderly CABG patients. Further investigations are needed to determine whether off-pump CABG is superior than on-pump CABG in elderly patients.

Are the Early Postoperative Outcomes of Coronary Artery Bypass Grafting Surgery in Elderly Women Worse Compared to Men's?

OBJECTIVE:: To investigate the impact of gender difference in early postoperative outcomes in elderly patients (aged 70 or older) undergoing coronary artery bypass grafting surgery. METHODS:: Between October 2009 and December 2013, a total of 223 elderly patients (aged 70 or older) undergoing isolated primary coronary artery bypass grafting surgery were included in this retrospective observational cohort study. Patients were divided into two groups according to their gender. The patients' medical records were collected, their baseline preoperative characteristics, operative data, and postoperative outcomes were retrospectively reviewed, and the effect of gender difference in the early postoperative outcomes was analyzed. RESULTS:: Group 1 (female patients) and Group 2 (male patients) consisted of 71 and 152 patients, respectively. Mean age of patients was 74.4±3.6 years (range: 70-84 years). The level of EuroSCORE I, the incidence of hypertension and hyperlipidemia were significantly higher in Group 1, while the rate of smoking was significantly higher in Group 2. Mean postoperative intubation time, length of intensive care unit and hospital stay were longer in female patients than in male patients, but these differences were not statistically significant. No statistically significant difference between two groups in terms of the transfusion of blood products was observed. The rates of in-hospital mortality and major postoperative complications were statistically similar between the two groups. CONCLUSION:: In conclusion, the female gender was not associated with worse early postoperative outcomes in elderly patients undergoing coronary artery bypass grafting surgery.

Are the early postoperative outcomes of coronary artery bypass grafting surgery in elderly women worse compared to men's?

Abstract Objective: To investigate the impact of gender difference in early postoperative outcomes in elderly patients (aged 70 or older) undergoing coronary artery bypass grafting surgery. Methods: Between October 2009 and December 2013, a total of 223 elderly patients (aged 70 or older) undergoing isolated primary coronary artery bypass grafting surgery were included in this retrospective observational cohort study. Patients were divided into two groups according to their gender. The patients' medical records were collected, their baseline preoperative characteristics, operative data, and postoperative outcomes were retrospectively reviewed, and the effect of gender difference in the early postoperative outcomes was analyzed. Results: Group 1 (female patients) and Group 2 (male patients) consisted of 71 and 152 patients, respectively. Mean age of patients was 74.4±3.6 years (range: 70-84 years). The level of EuroSCORE I, the incidence of hypertension and hyperlipidemia were significantly higher in Group 1, while the rate of smoking was significantly higher in Group 2. Mean postoperative intubation time, length of intensive care unit and hospital stay were longer in female patients than in male patients, but these differences were not statistically significant. No statistically significant difference between two groups in terms of the transfusion of blood products was observed. The rates of in-hospital mortality and major postoperative complications were statistically similar between the two groups. Conclusion: In conclusion, the female gender was not associated with worse early postoperative outcomes in elderly patients undergoing coronary artery bypass grafting surgery.

Long-term outcomes of pericardiectomy for constrictive pericarditis.

BACKGROUND: Constrictive pericarditis is a rare and disabling disease that can result in chronic fibrous thickening of the pericardium. The purpose of this study was to evaluate the long-term outcomes following treatment of constrictive pericarditis by pericardiectomy. METHODS: Between September 1992 and May 2014, 47 patients who underwent pericardiectomy for constrictive pericarditis were retrospectively examined. Demographic, pre-, intra- and postoperative data and long-term outcomes were analyzed. RESULTS: Thirty of the patients were male, the mean age was 45.8 ± 16.7. Aetiology of constrictive pericarditis was tuberculosis in 22 (46.8 %) patients, idiopathic in 15 (31.9 %), malignancy in 3 (6.4 %), prior cardiac surgery in 2 (4.3 %), non-tuberculosis bacterial infections in 2 (4.3 %), radiotherapy in 1 (2.1 %), uraemia in 1 (2.1 %) and post-traumatic in 1 (2.1 %). The surgical approach was achieved via a median sternotomy in all patients except only 1 patient. The mean operative time was 156.4 ± 45.7 min. Improvement in functional status in 80 % of patients' at least one New York Heart Association (NYHA) functional class was observed. In-hospital mortality rate was 2.1 % (1 of 47 patients). The cause of death was pneumonia leading to progressive respiratory failure. The late mortality rate was 23.4 % (11 of 47 patients). The mean follow-up time was 61.2 ± 66 months. The actuarial survival rates were 91 %, 85 % and 81 % at 1, 5 and 10 years, respectively. Recurrence requiring a repeat pericardiectomy was developed in no patient during follow-up. CONCLUSION: Pericardiectomy is associated with high morbidity and mortality rates. Cases with neoplastic diseases, diminished cardiac output, cases in need of reoperation are expected to have high mortality rates and less chance of functional recovery.

Association of Aortic Diameters with Coronary Artery Disease Severity and Albumin Excretion.

INTRODUCTION: Aortic diameters, aortic distensibility, microalbuminuria, coronary artery disease which are all together related to vascular aging are investigated in this paper. METHODS: Eighty consecutive nondiabetic patients undergoing elective coronary angiography were enrolled into the study. Systolic and diastolic aortic diameters, aortic distensibility, CAD severity by angiogram with the use of Gensini scoring, and albumin excretion rates were determined. RESULTS: Cases with CAD had significantly larger systolic (30,72 ± 3,21 mm versus 34,19 ± 4,03 mm for cases without and with CAD, resp.) and diastolic aortic diameters measured 3 cm above aortic valve compared to patients without CAD (33,56 ± 4,07 mm versus 29,75 ± 3,12 mm). The systolic and diastolic diameters were significantly higher in albuminuria positive patients compared to albuminuria negative patients (p = 0.017 and 0.008, resp., for systolic and diastolic diameters). CONCLUSION: In conclusion aortic diameters are increased in patients with coronary artery disease and in patients with microalbuminuria. In CAD patients, systolic blood pressure, pulse pressure, aortic systolic and diastolic pressure, and albumin excretion rate were higher and aortic distensibility was lower.

The relationship between cardiotrophin-1 and troponin-i in coronary arterial bypass grafting on the beating heart: a prospective study.

OBJECTIVE: Cardiotrophin-1 (CT-1) is closely associated with many cardiovascular diseases, such as hypertension, myocardial infarction (MI), and heart failure, and exhibits a cardioprotective effect in ischemia-reperfusion injury. The aim of this study was to evaluate the relationship between CT-1 and Troponin-I (Tn-I) in off-pump coronary artery bypass (OPCAB) grafting on the beating heart. METHODS: Seventy-eight patients (mean age 60.8 ± 9.7 years, 79.5% male) undergoing elective OPCAB surgery were included in this study undertaken between July 1, 2012 and July 1, 2013 in the Department of Cardiology and Cardiac Surgery, University School of Medicine Hospital. Venous blood samples were collected 5 minutes before OPCAB surgery and 6 hours after surgery. Plasma CT-1 levels were measured using the ELISA method. RESULTS: Compared to the preoperative period, Tn-I and CT-1 values were higher in the postoperative period [0.255 ng/mL (0.030-0.430) versus 0.045 ng/mL (0.005-0.090), P < .001; and 33.7 pg/mL (15.8-98.5) versus 8.7 pg/mL (0.68-25.4), P < .001]. There was also an elevation in white blood cells, aspartate aminotransferase, creatine kinase (CK), and creatine kinase MB (CK-MB) values, as well as a decrease in hemoglobin values (P < .001). When a correlation analysis for postoperative CT-1 was performed, there was a significant positive correlation between postoperative CK, CK-MB, and Tn-I levels (r = 0.250, P < .027; r = 0.270, P = .017; and r = 0.241, P < .034). CONCLUSION: CT-1 was found to be associated with Tn-I, which is used to detect myocardial damage after OPCAB surgery. CT-1 may also be used to detect myocardial damage.

Effects of off-pump versus on-pump coronary artery bypass grafting: apoptosis, inflammation, and oxidative stress.

BACKGROUND: It has been suggested that off-pump coronary artery bypass grafting (CABG) surgery reduces myocardial ischemia-reperfusion injury, postoperative systemic inflammatory response, and oxidative stress. The aim of this study was to measure serum malondialdehyde (MDA), high-sensitivity C-reactive protein (hs-CRP), M30, and M65 levels and to investigate the relationship between M30 levels and oxidative stress and inflammation in patients undergoing on-and off-pump CABG surgery. METHODS: Fifty patients were randomly assigned to on-pump or off-pump CABG surgery (25 patients off-pump and 25 on-pump CABG surgery), and blood samples were collected prior to surgery, and 30 minutes, 60 minutes, 6 hours, and 24 hours after CABG surgery. RESULTS: Compared to the on-pump group, serum MDA levels at 30 minutes, 60 minutes, 6 hours, and 24 hours after the CABG surgery were significantly lower in the off-pump group (P=.001, P=.001, P=.001, and P=.001, respectively). Serum M30 levels were found to be elevated in both groups, returning to baseline at 24 hours. When compared to baseline, the hs-CRP level reached its peak at 24 hours at 13.28±5.32 mg/dL in the on-pump group, and 15.44±4.02 mg/dL in the off-pump group. CONCLUSION: CABG surgery is associated with an increase in inflammatory markers and serum M30 levels, indicating epithelial/endothelial apoptosis in the early period.

Vascular complications of intra-aortic balloon pump usage in coronary bypass surgery: 18 years of experience.

OBJECTIVE: To evaluate the vascular complication incidence related to intra-aortic balloon pump usage during coronary bypass surgery and possible risk factors. METHODS: The retrospective study was conducted at Uludog University Hospital, Turkey, and comprised 147 cases in which intra-aortic balloon pump was used during coronary artery bypass surgery between January 1994 and December 2011. Data was examined in terms of age, gender, diabetes mellitus, hypertension, smoking, peripheral vascular disease, pre-operative serum creatinine, history of congestive heart failure, left ventricular ejection fraction, previous infarction and cardiac functional capacity. Time, indication, treatment duration, technique of insertion and complications were recorded about the balloon insertion. Patients in whom peripheral vascular complication developed were evaluated with pulse examination, Doppler ultrasound and angiography. Logistic regression analyses were carried out with the purpose of determining the relation between pre-operative clinical variables and vascular complications and mortality. RESULTS: Of the total, 105 (71%) were males and 42 (28%) were females. The overall mean age was 62.4 +/- 10.1 years. Besides, 16 (41%) cases had diabetes mellitus and 30 (20%) had peripheral artery disease. The mean Euroscore was 7.6 +/- 4.8. Intra-aortic balloon pump was inserted in 16 (10.8%) due to pre-operative high risk and in 75 (51%) cases due to hypotension being non-responsive to inotropes. Balloon catheter was placed with percutaneous technique in 141 (96%) cases and sheath wasn't used in 44 (29%). The balloon stayed for 2.9 +/- 2.1 days on average. Balloon rupture developed in 1 (0.6%) case. Mortality resulted in 58 (39%) cases. Euroscore (p=0.012), staying in hospital (p=0.005), low ejection fraction (p=0.018), hypertension existence (p=0.003) in multivariate logistic regression analyses were found significant in terms of affecting mortality. Duration of therapy (p<0.001), existence of sheath (p=0.002), and existence of peripheral vascular disease (p<0.001) were found significant as factors affecting the development of vascular complication. CONCLUSION: Intra-aortic balloon pump provides mechanical circulation assistance during coronary artery surgery, but peripheral vascular system should be well evaluated in order to avoid vascular complications and the balloon catheter should be placed without the sheath if necessary. The duration of the therapy is a risk factor for the development of vascular complication.

A rare reason for pulmonary hypertension: primary sarcoma of the pulmonary artery.

Primary sarcoma of the pulmonary artery (PSPA) is an extremely rare tumor of the cardiovascular system. The prognosis is very poor. The clinical symptoms and imaging findings imitate those of pulmonary emboli, causing delays in diagnosis. In this case report, we describe a 73-year-old man with PSPA who initially was admitted with exertional shortness of breath. Transthoracic echocardiographic evaluation revealed 2 masses in the pulmonary artery causing pulmonary hypertension. The patient underwent operation, but he could not be weaned off cardiopulmonary bypass at the end of the operation and died. Pathologic examination of the masses revealed pulmonary sarcoma. Although this patient was admitted to our clinic only 2 weeks after the initial symptoms, he already had distal metastases.

Diffuse involvement of the heart and great vessels in primary cardiac lymphoma.

Primary cardiac lymphoma (PCL) is an extremely rare disorder. In this report, a 57-year-old male with diffuse large B-cell lymphoma involving the heart and great vessels is presented. Trans-thoracic echocardiography was the first modality used to establish the diagnosis. Fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) showed diffuse increased metabolic activity of the heart walls and hypermetabolic lesions occupying cardiac chambers in some areas. The patient underwent systemic chemotherapy, and after 13 days, a marked regression of the tumour mass was evident based on echocardiographic examination. After completing six R-CHOP chemotherapy treatments, PET imaging was planned to control the residual mass, but the patient was intubated due to pneumonia that developed after the sixth chemotherapy session and subsequently died due to sepsis.

Coronary arteriovenous fistulas in the adults: natural history and management strategies.

OBJECTIVE: To describe aspects of the natural history and pathophysiology of coronary arteriovenous fistula and to propose potential treatment strategies. METHODS: Eleven adult patients were treated surgically for coronary arteriovenous fistulas (8 male, 3 female) during the last three years. Mean age was 48,7 +/- 9,5 years (range 32-65 years). Diagnosis was made by coronary angiography and transesophageal echocardiography RESULTS: All patients were symptomatic due to the associating cardiac disorder or fistula. Presenting symptoms were chest pain, exertional dyspnea and palpitation. All patients were diagnosed by selective angiography. Transthoracic and transoesophageal echocardiography was performed to identify the Qp/Qs ratio in one patient. One patient who had an LAD to pulmonary artery coronary arteriovenous fistula with a vascular malformation needed early reoperation due to recurrence of the fistula. Echocardiographic evaluation at the postoperative third month revealed no residual shunts in all patients. CONCLUSION: Because of the severe complications that may develop due to coronary arteriovenous fistula, we believe that every coronary artery fistula should be treated invasively by surgery or transcatheter closure. But both treatment modalities still need to be evaluated with randomized multicenter studies for long term survival and effectiveness.

Papillary fibroelastoma of the left atrial wall: a case report.

Cardiac papillary fibroelastoma is a rare, benign cardiac tumor. It often arises from valvular endocardium, and non-valvular endocardial location is rare. Although transthoracic echocardiography is usually sufficient for the diagnosis of most cardiac tumors, small tumors such as papillary fibroelastoma may be missed. Transesophageal echocardiography is superior to transthoracic echocardiography in diagnosing these tumors. Despite their benign histology, and independent of their size, they should be resected surgically because of their high potential for embolization. In this report, we present a case of papillary fibroelastoma located on the left atrial wall, presenting with symptoms of cerebral ischemia. The patient was treated surgically for the prevention of further embolic complications. Pertinent literature is also reviewed for this rare and benign cardiac tumor.

[Therapeutic approach in hemodynamically stable transmediastinal gunshot wounds]. / Hemodinamisi stabil transmediastinal atesli silah yaralanmalarinda tedavi yaklasimi.

Transmediastinal gunshot wounds may result in damage to the heart, large blood vessels, esophagus or lung. In hemodynamically stable patients, diagnostic examinations have critical importance and the preferred therapies still have unresolved points. In this paper, we present our experience with five patients, three of whom were operated for transmediastinal gunshot wounds after diagnostic tests; all were hemodynamically stable. Before deciding on operation, diagnostic tests should be performed in hemodynamically stable patients with transmediastinal gunshot wounds.

Aortic distensibility and coronary artery bypass graft patency.

BACKGROUND: Aortic distensibility is an elasticity index of the aorta, and reflects aortic stiffness. Coronary artery disease has been found to be substantially associated with increased aortic stiffness. In this study we aimed to retrospectively analyze the association of angiographically determined aortic distensibility with the patency rates of coronary bypass grafts METHODS: The study was conducted in the Cardiology department of the Applied Research Centre for Health of Uludag University. The coronary angiograms of 53 consecutive coronary bypass patients were analysed retrospectively. Aortic distensibility was calculated using the formula: 2 x (change in aortic diameter)/(diastolic aortic diameter) x (change in aortic pressure). The number of stenosed and patent bypass grafts and the patient characteristics like age, risk factors were noted. RESULTS: There were 44 male (83%) and 9 female (17%) cases. Eighteen cases had only one saphenous vein grafting. The number of cases with two, three and four saphenous grafting were 18, 11 and 1; respectively. In the control angiograms the number of cases with one, two, three and four saphenous vein graft obstruction were 15 (31.3%), 7 (14.6%), 1 (2.1%) and 1 (2.1%) respectively. The aortic distensibility did not differ in cases with and without saphenous graft occlusion (p > 0.05). Also left internal mammary artery (LIMA) graft patency was not related to the distensibility of the aorta (p > 0.05). We also evaluated the data for cut-off values of 50 and 70 mmHg of pulse pressure and did not see any significant difference between the groups in terms of saphenous or LIMA grafts. CONCLUSION: In this study we failed to show association of angiographically determined aortic distensibility with coronary bypass graft patency in consecutive 53 patients with coronary artery bypass graft surgery (CABG).

Spontaneous deep vein thrombosis in hemophilia A: a case report.

Venous thromboembolus is an important cause of hospital acquired morbidity and mortality. Venous thrombosis is a very rare occurrence in patients with haemophilia A. The thrombosis originated from the right main and external iliac veins, and effects the cranial segments of the main, deep and superficial femoral veins as an acute phase thrombus. Neither any local anatomic compression nor any predisposing thrombophilic risk factors were identified. We treated the patient with enoxaparine 1 mg/kg twice a day subcutaneously and then started oral anticoagulation with warfarin.

[Coronary-to-pulmonary artery fistulas: a report of three cases]. / Koroner arter ile pulmoner arter arasinda fistül: uç olgu sunumu.

Congenital coronary-to-pulmonary artery fistulas are rare anomalies and they generally have an asymptomatic course. We presented three symptomatic patients (2 men, 1 woman; age range 46 to 53 years) who underwent surgical repair via the epicardial approach for coronary-to-pulmonary artery fistulas. Treatment was successful in two patients. Reoperation in extracorporeal circulation was required in one patient having a plexus-like fistula. The distal orifice of the fistula was closed under direct vision from within the pulmonary artery. No complications or symptoms were seen during the follow-up of patients ranging from six months to four years. During repair of coronary-to-pulmonary artery fistulas, the presence of a plexus-like variant must be kept in mind and the treatment should be planned accordingly.