Pulmonary Endarterectomy in Patients with Antiphospholipid Syndrome-Associated Chronic Thromboembolic Pulmonary Hypertension.

BACKGROUND: Antiphospholipid syndrome is an autoimmune disease characterized by the occurrence of venous and/or arterial thrombosis. Chronic thromboembolism is one of the known established pathogenesis of pulmonary hypertension, known as chronic thrombo-embolic pulmonary hypertension. Pulmonary endarterectomy is the treatment of choice for chronic thromboembolic pulmonary hypertension. The aim of this study is to evalu-ate the efficacy and risk of pulmonary endarterectomy in patients with antiphospholipid syndrome-associated chronic thromboembolic pulmonary hypertension. METHODS: Data were prospectively collected and retrospectively analyzed, for patientswho underwent pulmonary endarterectomy between March 2011 and March 2020. RESULTS: Seventeen patients (4 male and 13 female) were identified. Thirteen patients had primary antiphospholipid syndrome and 4 had secondary antiphospholipid syndrome. The mean age was 34.82 ± 10.07 years and the mean time interval between the diagno-sis and surgery was 26.94 ± 17.35 months. Dyspnea on exertion was the main symptom in all patients. Seven patients had previous deep vein thrombosis, 5 patients had a history of recurrent abortions, and 2 patients had hemoptysis. Following surgery, mean pulmo-nary artery pressure decreased from 47.82 ± 13.11 mm Hg to 22.24 ± 4.56 mm Hg (P < .001), and pulmonary vascular resistance improved from 756.50 ± 393.91 dyn/s/cm-5 to 298.31 ±132.84 dyn/s/cm-5 (P < .001). There was no in-hospital mortality with a mean follow-up of 75.29 ± 40.21 months. The functional capacity of all patients improved from 269.46 ±111.7 m to 490 ± 105.34 m on a 6-minute walking test. CONCLUSIONS: Pulmonary endarterectomy is a safe and curative treatment in patientswith antiphospholipid syndrome-associated chronic thromboembolic pulmonary hyper-tension. It has a favorable outcome by increasing the quality of life. A multidisciplinary experienced chronic thromboembolic pulmonary hypertension team is critical in the management of these unique patients.

Repair of residual aortic dissections with frozen elephant trunk technique.

BACKGROUND: In this study, we present our mid-term results of reoperation with the frozen elephant trunk procedure due to patent false lumen-related complications in patients previously undergoing supracoronary aortic repair for acute type A aortic dissection. METHODS: Between January 2013 and September 2018, a total of 23 patients (17 males, 6 females; mean age 51.5±9.7 years; range, 30 to 67 years) who underwent ascending aortic replacement due to type A aortic dissection and, later, frozen elephant trunk procedure for residual distal dissection were included. For diagnostic purposes and follow-up, computed tomography angiography was performed in all patients, and both re-entry and aortic diameters were evaluated. Echocardiography was used to evaluate cardiac function and valve pathologies. RESULTS: The Ishimaru zone 0 (n=11, 47.8%), Ishimaru zone 1 (n=1, 4.3%), Ishimaru zone 2 (n=4, 17.4%), and Ishimaru zone 3 (n=7, 30.4%) were used for frozen elephant trunk stent graft fixation. The mean duration of cardiopulmonary bypass and antegrade selective cerebral perfusion was 223.9±71.2 min and 88.9±60.3 min, respectively. In-hospital mortality was 13%, while there was one (4.3%) aortic-related death and four (17.4%) re-interventions during follow-up. CONCLUSION: Early repair should be considered in the presence of persistent dissections due to alarmingly high mortality rates of reoperations. Reoperation with the frozen elephant trunk procedure has acceptable results and the decision of the procedure to be performed should be based on preoperative risk factors of the patient.

Surgical management of hypertrophic obstructive cardiomyopathy.

OBJECTIVE: Septal myectomy is the most effective treatment modality for hypertrophic obstructive cardiomyopathy. A retrospective study was conducted to evaluate outcomes of surgical myectomy alone or with concomitant mitral valve procedures. METHODS: From December 2011 through December 2016, a total of 41 patients with symptomatic hypertrophic obstructive cardiomyopathy were operated. There were 14 females and 27 males, aged between 18 and 73 years (mean 49.8 years). All patients had drug refractory symptoms (dyspnea, palpitation, chest pain, fainting, limitation of daily physical activities). Twenty-one patients received septal myectomy alone, 10 patients had SM with mitral valve repair and 10 patients had SM with mitral valve replacement. The average follow-up was 38.45 ± 12.18 months. RESULTS: Surgery led to symptomatic improvement in all patients. None of the patients were left with NYHA Class III and IV symptoms after surgery. The improvement in left ventricular outflow tract gradient was from 116.65 mmHg preoperatively to 22.47 mmHg. Mean septal thickness decreased from 2.35 to 1.74 cm. Post procedure permanent pacemaker implantation was required for one patient due to complete heart block, and 2 intracardiac devices were implanted due to resistant arrthymia. None of the patients required a repeat procedure during follow-up period. Operative mortality was 2.4%. CONCLUSION: Septal myectomy is safe and effective. Concomitant mitral operations do not increase morbidity and mortality.

Potential function of microRNAs in thoracic aortic aneurysm and thoracic aortic dissection pathogenesis.

Thoracic aortic aneurysm (TAA) and thoracic aortic dissection (TAD) are aortic diseases known as 'silent killers'. While TAA is characterized by an enlargement of at least half of the normal aortic diameter, TAD is characterized by progressive pseudo­lumen formation, which results in the gradual separation of the aortic wall layers. In the present study, a total of 28 serum samples from nine patients with TAA, nine patients with TAD and ten healthy individuals were studied. The aim of the present study was to investigate the expression profiles of hsa­microRNA(miR)­143­3p and hsa­miR­22­3p in TAA and TAD in order to identify candidate miRNAs that are responsible for the pathogenesis of the diseases. Following the detection of target mRNAs from candidate miRNAs by bioinformatic tools, the expression profiles of target mRNAs were analyzed. A quantitative polymerase chain reaction was performed to detect Kirsten rat sarcoma viral oncogene homolog (KRAS), mitogen­activated protein kinase (MAPK) 7, MAPK14 and transgelin (TAGLN) mRNA expression profiles. The results of the comparison with control group demonstrated that the increase in the expression levels of hsa­miR­143­3p (P=0.017) and hsa­miR­22 (P=0.03) candidate miRNAs were statistically significant in the TAA group, but not in the TAD group. The expression of KRAS and MAPK7 mRNAs decreased in the two groups compared with the control group. The level of expression of MAPK14 decreased in the TAD group, but increased in the TAA group compared with the control group. TAGLN mRNA expression level increased in the two groups. The statistically significant difference in the expression of hsa­miR­143­3p suggests that hsa­miR­143­3p may be a potential biomarker for TAA, as the expression of the target mRNAs KRAS and MAPK7 decreased and the miRNA­mRNA association was negatively correlated. These miRNAs and their associated genes may serve important functions in TAA formation, the altered expression of which may be important in the pathogenesis of TAA.

Prognostic significance of the absence of normal septal Q waves before aortic valve replacement.

PURPOSE: Aim of this study was to investigate the prognostic significance of absence of septal Q waves in patients scheduled for aortic valve replacement. MATERIAL AND METHODS: Sixty-one patients who underwent isolated aortic valve replacement for aortic stenosis were retrospectively evaluated. Septal Q waves were defined as Q waves of<2mm in amplitude and<40ms in width and absence of septal Q waves was defined as simultaneous loss of Q waves from at least three of the leads I, aVL, V5 and V6. Septal Q waves were absent in 17 patients (Group AQ, 27.8%) and were present in 44 patients (Group PQ, 72.1 %) preoperatively. Newly developed AV block>1st degree and newly developed left bundle branch block were primary endpoints. RESULTS: Preoperatively, absence of normal septal Q waves was significantly associated with increased risk of postoperative AV block (HR: 11.18, range 1.37-91.21, 95% CI, p=0.02) whereas it was not associated with increased risk for newly developed LBBB (HR: 3.15 0.62-15.83, 95% CI, p=0.16). CONCLUSION: Absence of normal septal Q waves in the preoperative ECG may predict further delay in conduction which might develop in the early postoperative course of aortic valve replacement.

Surgical repair of a congenital left ventricular aneurysm.

Congenital left ventricular aneurysm is an uncommon cardiac malformation. A 9-year-old boy with complaints of dyspnea and palpitation was diagnosed with a left ventricular aneurysm originating from the left ventricle free wall. Aneurysm resection and endoventricular patch repair was performed. Postoperative follow-up was uncomplicated and follow-up echocardiographs showed normal left ventricular contractility.

Operative correction of cor triatriatum sinister with systemic venous return anomaly (inferior vena cava-left atrium).

Cor triatriatum sinister is a rare cardiac anomaly. It is characterized by the presence of a fibromuscular membrane in the left atrium, thus forming a proximal chamber receiving the pulmonary veins and a distal chamber communicating with the mitral valve and the left atrial appendage. This rare pathology tends to coexist with a persistent left superior vena cava, whereas the presence of an anomalous systemic venous return is unusual. In this article, we report successful treatment of a patient with cor triatriatum sinister who has an additional systemic venous return anomaly.

Does aortic root enlargement impair the outcome of patients with small aortic root?

BACKGROUND: Posterior root enlargement procedures provide the implantation of suitable-sized prosthetic valves in patients with a small aortic root to prevent a high postoperative transvalvular gradient. The aim of this study was to evaluate long-term results of the posterior root enlargement. METHODS: Between 1985 and 2002, 124 patients underwent aortic valve replacement with a posterior root enlargement. The main indication was a small aortic valve orifice area to patient body surface area (indexed valve area < 0.85 cm2/m2). Fifty-four (44%) patients were male, and 70 (56%) were female with a mean age 39.1 +/- 14.3 years. Indications for operation were severe calcified aortic valve stenosis (37.1%), severe aortic insufficiency (25.8%), or combination (37.1%). Seventy-five (60%) patients received double-valve replacement. A pericardial patch was used in 100 patients (80.6%) and a Dacron patch was used in 24 patients. RESULTS: Operative mortality was 6.4% (8 patients). The causes of hospital mortality were low cardiac output syndrome (LCOS) (in 6 patients), cerebrovascular events (in 1 patient) and multiple organ failure (in 1 patient). Multivariate analysis demonstrated concomitant coronary revascularization to be a significant (p = 0.03) predictor for early mortality. There were six (5.4%) late deaths. Cox proportional hazards regression analysis demonstrated LCOS (p = 0.013) and infective endocarditis (p = 0.003) to be significant predictors for late mortality. Atrioventricular block required a permanent pacemaker was observed in 4 patients (3.2%). CONCLUSIONS: Posterior aortic root enlargement techniques can be easily applied without additional risks. Long-term survival and freedoms from valve-related complications are satisfactory.

Pericardiectomy for chronic constrictive tuberculous pericarditis: risks and predictors of survival.

We performed this study to determine the predictors of early and long-term survival in the surgical treatment of tuberculous pericarditis and to examine the risks of pericardiectomy and the functional outcome in patients after surgery. A retrospective analysis was undertaken in 36 consecutive patients, 26 female and 10 male, with a mean age 32.2 +/- 16.3, who underwent pericardiectomy for chronic constrictive pericarditis from February 1985 to February 2002. All patients received antitubercular therapy in the postoperative period. The operative mortality rate was 6% (2 patients); the cause of death in both cases was severe low-cardiac-output syndrome. Nonfatal intraoperative complications affected 3 patients (8%). The median stay in the intensive care unit was 3.7 +/- 3.1 days. The median hospital stay was 14 +/- 2.6 days. The median ventilation time was 11.9 +/- 1.8 hours. The median volume of blood transfused was 2.1 +/- 1.6 units. Advanced age, atrial fibrillation, concomitant tricuspid insufficiency, inotropic support and low cardiac output were significant negative predictors of survival, according to univariate analysis. There were 4 late deaths. Actuarial survival at 5 years was 75.9% +/- 9.14%. At the 1-year follow-up examination, improved functional status was noted in 88% of patients. We suggest that pericardiectomy be performed early and as radically as possible, in an effort to prevent chronic illness. A combination of chemotherapy and surgery yields gratifying results in the treatment of tuberculous pericarditis.