Increased deep vein thrombosis cases during the COVID-19 quarantine.

OBJECTIVE: The aim of this study was to compare the number of deep vein thrombosis (DVT) cases during the quarantine period for COVID-19 to that of the last year. METHODS: This study was conducted as a single-center and retrospective study. All hospital admissions during April 2020 and May 2020 were screened from the hospital records, and DVT cases were recorded. Likewise, all hospital admissions during April 2019 and May 2019 were screened, and DVT cases were noted. DVT cases of both years were compared. RESULTS: Among 480931 patients admitted to our hospital in April 2019 and May 2019, DVT was detected in 82 patients (0.017%) (47 males, 35 females) with a mean age of 56.99 ± 9.1 years (ranges 39 to 79 years). Besides, among 145101 patients admitted to our hospital in April 2020 and May 2020, DVT was detected in 123 patients (0.084%) (51 males, 72 females) with a mean age of 58.64 ± 8.9 years (ranges 40 to 83 years). Despite the decrease in the total number of patients admitted to the hospital, there was a significant increase in the number of DVT patients. Interestingly, there were only two symptomatic pulmonary-embolism cases in the 2019 period, whereas there were seven symptomatic pulmonary embolisms secondary to DVT in the 2020 period. Unfortunately, one patient died due to pulmonary embolism secondary to DVT in 2020. The previous history of DVT was remarkable in patients admitted during the COVID-19 confinement. CONCLUSION: In conclusion, COVID-19 confinement seems to be associated with increased rates of DVT. Strict preventive measures such as exercise training or prophylactic drug use should be considered to prevent immobility-related DVT during the COVID-19 quarantine.

Repair of calcified left ventricular pseudoaneurysm of long duration.

Cardiac pseudoaneurysm is a contained rupture of the myocardium limited by pericardial adhesions or the epicardial wall. Cardiac pseudoaneurysm may cause sudden death with a mortality of 30-45% in the first year, mostly resulting from rupture. Coronal and axial T2-weighted magnetic resonance images of a 65-year-old male patient admitted with dyspnoea, coughing and chest pain, present for the last 10 days, revealed a large pseudoaneursym of the left ventricle. Coronary bypass and left ventricular restoration operation was performed. The patient was eventlessly discharged 8 days after operation. He is in NYHA Class I 21 months postoperatively. The interval between myocardial insult and establishment of diagnosis is unknown in our patient. This is a patient whose left ventricular rupture had been contained for a very long time, possibly years, because a heavily calcified thick pseudoaneurysm wall was encountered during operation, making this case rare in the literature.

Long-Term Results of Pericardial Autologous Patch Enlargement of the Aortic Annulus Using the Manouguian Technique.

BACKGROUND: The management of a small aortic root at the time of aortic valve replacement is controversial. In cases in which the aortic root is very small the choice of aortic valve type and of root-enlargement method is difficult. The technical challenge of the small aortic root has instigated the creation of methods for annular enlargement. Severe mismatch as a predictor of overall 30-day mortality or midterm mortality reports about long-term results of aortic valve replacement using autologous pericardial patch are scarce. Moreover, no reports about patient series are present in the English medical literature. This retrospective study was designed to address this gap in evidence. METHODS: Twenty consecutive patients undergoing aortic valve replacement (with or without mitral valve replacement and/or coronary artery bypass grafting) at Baskent University Adana Medical Center between June 30, 1999 and April 10, 2006 were retrospectively evaluated. All clinical and echocardiographical data belonging to this population were specified. Their perioperational data were assessed. RESULTS: Twenty patients operated using the Manouguian technique for narrow aortic root from June 1999 to April 2006 were followed for 8.54 ± 3.35 years. Fourteen patients were alive at the end of the follow-up. Six patients had died. Early mortality rate was 5% and late mortality after 8.54 ± 3.35 years was 30%. Late mortality related to cardiac reasons was 5%. Only one death could be attributed to a cardiac cause which occured in a 36-year-old male patient 3 years and 6 months after the operation. 70% of the patients were alive after a mean follow-up period of 8.54 ± 3.35 years. CONCLUSION: The main finding of the present study is that aortic root enlargement using untreated fresh autologous pericardium in Manouguian type operations is a durable option, especially in conditions when homograft or stentless valve use is difficult or economically not feasible. We found that no patient had aneurysmal dilatation or mitral regurgitation after a mean follow-up of 8.54 ± 3.35 years with autologous untreated pericardium as the enlargement patch.

Risk factors for systemic inflammatory response after congenital cardiac surgery.

BACKGROUND: This study aims to assess the frequency of systemic inflammatory response syndrome (SIRS) following congenital heart surgery and risk factors associated with this clinical syndrome. METHODS: Charts of all patients undergoing surgery for congenital heart disease in a single institution over a five-year period were analyzed retrospectively. The presence of SIRS was evaluated based on the criteria of the International Pediatric Sepsis Consensus Conference. RESULTS: Of the 246 patients included in the study 22 (8.9%) had clinical parameters indicating SIRS. The patients in the SIRS group had significantly longer cardiopulmonary bypass time (105.14 ± 27.27 vs. 66.86 ± 26.64 min; p < 0.01), aortic cross clamp time (69.36 ± 21.52 vs. 44.30 ± 24.27 min; p < 0.01), higher postoperative alanine aminotransferase (1419.00 ± 3260.99 vs. 81.95 ± 808.61 U/L; p < 0.01) and aspartate aminotransferase (2137.14 ± 4905.40 vs. 171.33 ± 1303.21 U/L; p < 0.01), white blood cell counts (20,827 ± 3603 vs. 12,242 ± 3782/µL; p < 0.01) and lower body surface area (0.52 ± 0.32 vs. 0.71 ± 0.36 m(2) ; p < 0.05) compared to patients in the no-SIRS group. Binary logistic regression revealed cardiopulmonary bypass time (OR: 1.05, p < 0.05), low body weight (<10 kg) (OR: 2.44; p < 0.05), and preoperative diagnosis of right to left shunt congenital heart disease (OR: 8.06; p < 0.01) as independent predictors of SIRS. SIRS was also found to be a strong independent predictor of mortality (OR: 10.13, p < 0.01). CONCLUSIONS: SIRS after congenital heart surgery is associated with increased mortality. Independent risk factors for SIRS in the patient population of the study were cardiopulmonary bypass time, body weight below 10 kg and preoperative diagnosis of right to left shunt congenital heart disease.

Positive clinical outcomes of the saphenous vein interposition technique for ruptured popliteal artery aneurysm.

PURPOSE: Popliteal artery aneurysms (PAAs) can be treated successfully by surgical and endovascular methods; however, the best treatment strategy for a ruptured PAA has yet to be established. We assessed the clinical results of using saphenous vein interposition to treat ruptured PAAs in our hospital. METHODS: The subjects of this study were seven men (average age 59 years, range 43-71 years), who underwent emergency surgery for a ruptured PAA at our hospital between January 2007 and November 2012. The patients were assessed after 1, 6, and 12 months, postoperatively. RESULTS: All included patients underwent saphenous vein graft interposition via a medial approach. No complications or graft thromboses were encountered in the immediate postoperative period. The patients were discharged after an average of 4 days postoperatively (range 3-5 days). The patients were followed up for an average of 32 months (range 2-60 months). The medium-term graft patency was 100%. No patients suffered early or medium-term limb loss and there was no mortality. CONCLUSION: Based on our positive results, saphenous vein graft interposition should be considered as the first choice of surgical treatment for a ruptured PAA.

Evaluation of coronary artery-saphenous vein composite grafts: the aortic no-touch technique.

We retrospectively compared the results of conventional coronary artery bypass grafting (CABG) performed on patients who showed no preoperative evidence of serious atherosclerosis of the ascending aorta with the results of the aortic no-touch technique (using coronary artery-saphenous vein composite grafts) on CABG patients who did show such evidence. From 2003 through 2012, 3,152 consecutive patients underwent isolated primary CABG at our hospital. We chose 360 for the current study. The study group (n=120) comprised patients who had undergone operation via the aortic no-touch technique. Propensity-score-matching (1:2) was used to select the control group of 240 patients who had undergone conventional CABG. Early and late survival rates, reintervention-free survival rates, and freedom from cardiac death were compared. Early and late mortality rates were similar in the study and control groups (P=0.19 vs P=0.29, respectively), as were cardiac-related death (2.5% vs 2.1%, respectively; P=0.53) and overall death (8.3% vs 7.9%, respectively; P=0.51). Overall survival rates were 91.7% vs 92.1% and freedom-from-cardiac-death rates were 97.4% vs 97.5% (P=0.71 vs P=0.78, respectively; mean follow-up period, 5.27 ± 2.51 yr). Reintervention-free survival rates were also similar (96.7% vs 98.8%, respectively; P=0.2). As a result of the similar rates of early and late survival, reintervention-free survival, and freedom from cardiac death, we conclude that the aortic no-touch technique with composite grafts might be a reasonable option in patients who have atherosclerotic ascending aorta that cannot be clamped.

Large pseudoaneurysm of the sinus of Valsalva after surgery for aortic valve endocarditis.

Patients who undergo prosthetic aortic valve replacement for infective endocarditis and have no recurrent infection after surgery, rarely develop pseudoaneurysm of either the aortic root or the sinus of Valsalva (SV). Pseudoaneurysm of the SV can have fatal complications, including rupture. The case is reported of a large pseudoaneurysm of the SV that developed after surgical intervention for aortic valve endocarditis, and which was successfully treated.

Results of additional pulsatile pulmonary blood flow with bidirectional glenn cavopulmonary anastomosis: positive effect on main pulmonary artery growth and less need for fontan conversion.

BACKGROUND: Additional antegrade pulsatile pulmonary blood flow obtained by leaving the main pulmonary artery patent during bidirectional cavopulmonary shunt has been shown to give additional benefits to the bidirectional Glenn cavopulmonary anastomosis. We retrospectively evaluated our 20-patient pulsatile Glenn series in order to find out whether these salutary effects were valid or not. METHODS: Between June 2007 and November 2011, 20 patients (11 girls and 9 boys) with single-ventricle physiology underwent bidirectional cavopulmonary anastomosis. The additional source of blood flow was through the unligated main pulmonary artery in all patients. A retrospective review of our surgical experience was performed focusing on the role of additional pulmonary flow. Medical records and perioperational and postoperative follow-up data including clinical outcomes were retrospectively retrieved and analyzed. RESULTS: Two patients died in the early postoperative period. One patient died in the follow-up period. Mean follow-up time was 23.9 ± 15.7 months. No superior vena cava syndrome and no increase in pulmonary vascular resistance were observed. Improvement of partial oxygen pressure after pulsatile Glenn has been shown in all patients (P = .00). At a mean interval of 22.9 months, main pulmonary artery size continued to increase after pulsatile Glenn cavopulmonary anastomosis (P = .028). Only 1 patient was converted to Fontan type circulation after pulsatile Glenn cavopulmonary anastomosis. CONCLUSIONS: The pulsatile cavopulmonary shunt is a useful procedure in the early and intermediate term management of patients with a functional univentricular heart. It improves partial oxygen pressure and the impact of pulsatility on the main pulmonary artery.

Pre- and perioperative risk factors predicting neurologic outcomes after coronary artery bypass surgery in patients with pre-existing neurologic events.

BACKGROUND: A neurologic event (NE) after coronary artery bypass graft (CABG) surgery is a principal complication affecting morbidity and mortality. We investigated the risk factors predicting postoperative NEs and survival in patients with pre-existing NE undergoing CABG. METHODS: Between 2001 and 2012, 3137 patients underwent isolated primary CABG. The data were stored in a computerized database and retrospectively evaluated. Patients were divided into 2 groups based on the existence of preoperative NE (study group; n=126) and without NE (n=3011). Uni- and multivariate logistic regression analyses were performed to evaluate the possible predictors of postoperative NEs. Survival was determined using Kaplan-Meier survival analyses of the study group and propensity score-matched control group. RESULTS: The mean age of the 3137 patients was 60±9 years, and 28% (n=885) were female. Postoperative NE was seen in 4 (3.2%) patients with pre-existing NE and in 16 (0.5%) without pre-existing NE. Preoperative NE (odds ratio 4.47; 95% confidence interval 1.32-15.18; P=.01) and age (≥70 years; odds ratio 2.98; 95% confidence interval 1.21-7.33; P=.01) showed strong multivariate associations with postoperative NE. Median CHA2DS2-VASc scores were 4.5 (interquartile range 3-5) and 3 (range 0-4) in patients in the pre-existing and without NE groups, respectively (P=.01). The overall mean follow-up was 4.6±3 years. Overall survival rates (88.1% and 94%, respectively) were different between the 2 groups (P=.02). CONCLUSIONS: Preoperative neurologic events and advanced age are significant risk factors predicting postoperative neurologic events. Meticulous management of the ascending aorta and carotid artery are important in diminishing postoperative neurologic events. A pre-existing neurologic event is also predictive for decreased overall survival.

Endovascular treatment and the long-term results of postpartum deep vein thrombosis in 18 patients.

PURPOSE: We aimed to describe the long-term outcome of endovascular treatment of iliofemoral deep vein thrombosis in the postpartum period. MATERIALS AND METHODS: Between 2002 and 2010, 18 consecutive female patients with acute or subacute iliofemoral deep vein thrombosis in the postpartum period who had endovascular treatment were retrospectively evaluated. Treatment consisted of manual aspiration thrombectomy with or without catheter-directed thrombolysis. Stents were placed in the iliac veins, if deemed necessary. Clot removal was graded as complete (>95%), partial (50%-95%), and poor (<50%). RESULTS: The initial treatment was technically successful in 17 patients (94%). There was complete clot removal in 15 of 22 limbs (68%). Twenty-three stents were implanted in 15 patients (83%). The primary and secondary patencies were 58% and 82% at one year, 58% and 72% at three years, and 58% and 58% at five years, respectively. There were recurrent thromboses in 11 patients (61%), which occurred within the first month in nine of these patients (81%). Ten patients had repeated intervention, and five had successful outcomes. At a mean follow-up of 30 months, 11 patients had uninterrupted in-line flow in the affected lim b, and six patients did not. Six of the patients with uninterrupted flow were asymptomatic, and five patients had minimal swelling at the ankle. CONCLUSION: Endovascular treatment of postpartum iliofemoral deep vein thrombosis with percutaneous aspiration thrombectomy alone or combined with catheter-directed thrombolysis and iliac vein stenting is an effective therapy resulting in a high rate of thrombus removal. However, recurrences are high, particularly in the first post-intervention month. Frequent patient followup in the first post-intervention month is necessary.

Papillary fibroelastoma of the right coronary cusp.

Cardiac papillary fibroelastoma (CPF) is a pathologically benign cardiac tumor. This tumor usually arises from cardiac valves, and it is the most common cardiac valvular tumor. This usually single and pedunculated tumor should be surgically treated when the mass is mobile and the patient has experienced a prior stroke, even if the stroke has manifested as a transient ischemic attack. Surgical treatment is definitive, and no recurrences have been reported in the literature. We describe a patient who had a diagnosis of CPF while undergoing investigation for a cryptogenic stroke.

The efficacy of intravenous patient-controlled remifentanil versus morphine anesthesia after coronary artery surgery.

OBJECTIVE: To compare the effect of remifentanil and morphine after coronary artery surgery in a patient-controlled analgesia (PCA) protocol. DESIGN: A prospective, randomized, double-blind clinical study. SETTING: Single institution, university hospital. PARTICIPANT: Sixty cardiac surgical patients undergoing primary coronary artery bypass graft (CABG) surgery. INTERVENTIONS: After the operation, patients were allocated to 1 of 2 groups. In the first group (group R, n = 30), the following intravenous PCA protocol was programmed: remifentanil infusion, 0.05 microg/kg/min; bolus, 0.25 microg/kg; and lockout time, 5 minutes. In the second group (group M, n = 30), the intravenous PCA protocol was as follows: morphine infusion, 0.3 mg/h; bolus, 1 mg; and lockout time, 5 minutes. In addition to intravenous opioids, paracetamol was administered during the study. In both groups, tramadol was added to the regimen after PCA had been terminated at 24 hours after surgery. In addition to tramadol and paracetamol, 10 mg of morphine sulfate was administered if the numeric rating scale (NRS) score for pain was 3 or more after the first postoperative day. Pain was assessed with an NRS in each patient at rest, while coughing, and during movement for 72 hours. Sedation levels were measured with the Ramsay sedation scale. Overall effectiveness of pain relief was evaluated with a 4-stage scale ("very good," "good," "moderate," or "bad"). MEASUREMENTS AND RESULTS: During coughing, the NRS values were statistically significantly lower in group R than they were in group M at 12 and 24 hours after surgery (median 1 vs 3 at 12 hours and 2 v 3.5 at 24 hours) (p < 0.05). On movement, NRS values were statistically significantly lower in group R than they were in group M at 12 hours after surgery (median 1 v 2.5) (p < 0.05). After the first 24 hours, the requirement for additional analgesia was similar in both groups. The overall effectiveness of pain relief was rated "very good" or "good"' in 87% of patients in group R and in 72% of patients in group M (p > .05). CONCLUSION: There was no difference in patient satisfaction between the 2 groups. On the basis of the reduction of pain scores (with cough and movement) at 1 or 2 postoperative time points, PCA-remifentanil infusion is a better analgesic technique; overall, both PCA techniques provided for effective pain scores (<3). In patients in whom PCA morphine is contraindicated after CABG surgery, PCA remifentanil is a safe alternative.

Repair of aortic coarctation and aneurysm of ductus arteriosus in the presence of right-sided arch and descending aorta.

Association of right aortic arch and coarctation of the aorta is rare. A patient with aortic coarctation was presented to our clinic. Detailed radiological work-up revealed aortic coarctation, aneurysm of ductus arteriosus, mirror image brachiocephalic vessels, right-sided arch, and right-sided descending aorta. The patient underwent successful operative repair through a right thoracotomy. She is normotensive and doing well two years postoperatively.

Cannulation of the ascending aorta in left thoracotomy for thoracic aortic aneurysms.

In patients with aneurysms of the thoracic aorta, the risks of cerebral embolism and malperfusion are increased if retrograde aortic perfusion via the femoral artery is used during repair. We describe a surgical technique used for 6 aneurysms of the thoracic descending aorta that were operated on via thoracotomy with cannulation of the ascending aorta and deep hypothermic circulatory arrest.

Magnesium decreases cardiac injury in patients undergoing coronary artery bypass surgery.

BACKGROUND: The calcium-channel blocking effect of magnesium might have protective effects in patients undergoing cardiopulmonary bypass surgery. We assessed the effects of magnesium on hearts undergoing coronary artery bypass surgery with intermittent warm blood hyperkalemic cardioplegia in the antegrade fashion. PATIENTS AND METHODS: Twenty patients undergoing coronary bypass surgery were randomly divided into two groups, a control group who received intermittent antegrade warm blood hyperkalemic cardioplegia for myocardial protection, and a study group who received the same solution with the addition of magnesium to the cardioplegia. Extracellular substrates (creatinine phosphokinase, creatinine phosphokinase-MB group, lactate dehydrogenase, c-reactive protein, and cardiac troponin I were measured preoperatively and postoperatively. RESULTS: There were significant differences in the post-operative concentrations of creatinine phosphokinase, creatinine phosphokinase-MB group, c-reactive protein, and lactate dehydrogenase after cardiopulmonary bypass (P<0.001) in the study group compared with the control subjects. Cardiac troponin I levels were also significantly lower in the study group after cardiopulmonary bypass (P<0.005). CONCLUSIONS: Our study indicates that if magnesium is added to intermittent antegrade warm blood hyperkalemic cardioplegia, blood levels of many markers of cardiac myocardial injury after cardiopulmonary bypass are lowered. This finding may have implications for myocardial protection.