Evaluation of Anastomosis Efficiency in Arteriovenous Shunts Created by Using Hand-Sewn Microsurgery and Microvascular Anastomotic Coupler Device.

OBJECTIVE: Microsurgery has made great contributions to the advancement of surgery. In parallel with the developments in microsurgery, various techniques have been developed to perfect the technique. Microvascular anastomotic coupler device (MACD) is one of these techniques. The aim of the study was to evaluate the effectiveness of anastomoses created by using hand-sewn microsurgery (HSM) and MACD. METHODS: Twenty male Sprague-Dawley rats weighing 250 to 300 g were divided into 2 groups randomly. Arteriovenous shunt was performed between carotid artery and internal jugular vein with the principles of HSM in the first group (n=10) and by using the 1-mm anastomotic microvascular device in the second group (n=10). Groups were evaluated for anastomose time, success of anastomosis, thrombosis formation, color Doppler ultrasonography, and histopathological features. RESULTS: Anastomotic time was faster with the coupler device compared with HSM technique. Flow rates were found significantly higher in the MACD group. Endothelialization and wall integrity rates were better in MACD group. CONCLUSIONS: Microvascular anastomotic coupler device is faster than HSM. High quality and durability of vascularization, insignificant foreign body reactions are histopathological advantages of MACD.

Rare vascular involvement in Behçet's disease: Coronary artery pseudoaneurysm.

Behçet's disease is a relapsing, inflammatory, multi-systemic disease. Coronary arterial involvement in Behçet's disease is very rare with a prevalence of less than 0.5%. We report the case of a 34-year-old man who presented with a coronary artery pseudoaneurysm associated with Behçet's disease. The patient underwent a successful left internal thoracic artery to left anterior descending artery bypass graft procedure, and remains symptom-free in a 6-month follow up with normal electrocardiogram.

A combination of severe complications in a case of infective endocarditis: Dehiscence of prosthetic aortic valve, aortic dissection, pseudoaneurysm, and hematoma causing right ventricular collapse.

Prosthetic valve endocarditis with mechanical complications causing pulmonary edema is fatal, therefore it needs to be diagnosed early and should be treated surgically in emergency setting. Transesophageal echocardiogram is crucial for recognizing the mechanical complications, which can be encountered on daily practice, but the coexistence of complications occurring on different mechanism is rather uncommon. Herein, we report a 21-year-old gentleman presenting with acute heart failure, whose imaging tests showed a combination of dehiscence of mechanical aortic valve prosthesis, aortic dissection, pseudoaneurysm, and hematoma causing right ventricular collapse.

The Effect of Hemodynamic Parameters on Cerebral Oxygenization During Carotid Endarterectomy

Abstract Objective/Introduction: Near-infrared spectroscopy (NIRS) is a non-invasive technique to detect cerebral ischemia by monitoring changes in regional cerebral oxygenation (rSO2) in the frontal lobes. However, there are no studies showing the changes in NIRS values in response to hemodynamic variations during stages of carotid endarterectomy (CEA) procedure and clinical implications of these changes. The aim of this study was to determine if hemodynamic changes affect NIRS values during carotid endarterectomy and if our results may help to provide strategies for hemodynamic management in these patients. Methods: A total of 50 consecutive patients undergoing CEA were prospectively included in the study. NIRS was measured at first minute after clamping of carotid artery, and then systolic blood pressure was increased above 150 mmHg. NIRS values from both hemispheres were recorded simultaneously at certain time points and were analyzed to evaluate the changes at different stages of operation and to assess correlations with hemodynamic parameters. Results: NIRS values on the right and left sides were correlated with systolic (right P<0.001, R2:0.24; left P=0.02, R2:0.10) diastolic (right P<0.001, R2:0.36; left P=0.001, R2:0.18) and mean (right P<0.001, R2:0.33; left P=0.003, R2:0.17) blood pressures when the patient was under general anaesthesia. NIRS values were significantly lower than pre-incision values just after clamping of carotid artery in both hemispheres (P=0.005 for the right and P<0.001 for the left side). Conclusion: NIRS values measured in our study show that there is a correlation between hemodynamic changes and cerebral oxygenation. This effect is especially pronounced while the patient is asleep and intubated, which implies the importance of close monitoring of patients with carotid disease during any surgery requiring general anaesthesia.

The role of immature platelet count and immature platelet fraction in determining the need for transfusion in patients undergoing CABG.

BACKGROUND: Platelet dysfunction has been shown to play a role in postoperative bleeding, however it is not clear whether immature platelets (IP) can induce appropriate homeostasis to prevent excessive bleeding in patients undergoing coronary artery bypass grafting (CABG). The aim of this study was to evaluate the postoperative change in IP count (IPC), IP fraction (IPF) and mean platelet volume (MPV), and to examine their relationship with postoperative bleeding and blood transfusion. METHODS: One hundred and forty-nine consecutive patients undergoing elective CABG were included in this prospective study. All CABGs were performed by the same surgical team in a standardised method, utilising the on-pump technique. IPC, MPV and IPF were measured pre-operatively, after the completion of surgery, and at the postoperative first, third and fifth days. The primary outcome measure of this study was whether the need for transfusion was associated with IP, IPF, MPV and platelet count. RESULTS: There was a significant decrease of 7.77% in IPC on the day of the operation. Pre-operative IPC and IPF were correlated with postoperative drainage (p < 0.001), intraoperative blood transfusion (p < 0.001) and intensive care unit blood transfusion (p < 0.001). Pre-operative haemoglobin levels were significantly correlated with length of hospital stay. However, neither pre-operative IPC nor IPF were associated with length of hospital stay. Postoperative IPC was however associated with the length of hospital and intensive care unit stay (p = 0.008 and p = 0.009, respectively). CONCLUSIONS: Pre-operative IPC and IPF were significantly correlated with postoperative drainage and blood transfusion frequency. In patients undergoing CABG, these can be seen as serious guiding parameters in the estimation of postoperative bleeding.

The Effect of Hemodynamic Parameters on Cerebral Oxygenization During Carotid Endarterectomy.

OBJECTIVE/INTRODUCTION: Near-infrared spectroscopy (NIRS) is a non-invasive technique to detect cerebral ischemia by monitoring changes in regional cerebral oxygenation (rSO2) in the frontal lobes. However, there are no studies showing the changes in NIRS values in response to hemodynamic variations during stages of carotid endarterectomy (CEA) procedure and clinical implications of these changes. The aim of this study was to determine if hemodynamic changes affect NIRS values during carotid endarterectomy and if our results may help to provide strategies for hemodynamic management in these patients. METHODS: A total of 50 consecutive patients undergoing CEA were prospectively included in the study. NIRS was measured at first minute after clamping of carotid artery, and then systolic blood pressure was increased above 150 mmHg. NIRS values from both hemispheres were recorded simultaneously at certain time points and were analyzed to evaluate the changes at different stages of operation and to assess correlations with hemodynamic parameters. RESULTS: NIRS values on the right and left sides were correlated with systolic (right P<0.001, R2:0.24; left P=0.02, R2:0.10) diastolic (right P<0.001, R2:0.36; left P=0.001, R2:0.18) and mean (right P<0.001, R2:0.33; left P=0.003, R2:0.17) blood pressures when the patient was under general anaesthesia. NIRS values were significantly lower than pre-incision values just after clamping of carotid artery in both hemispheres (P=0.005 for the right and P<0.001 for the left side). CONCLUSION: NIRS values measured in our study show that there is a correlation between hemodynamic changes and cerebral oxygenation. This effect is especially pronounced while the patient is asleep and intubated, which implies the importance of close monitoring of patients with carotid disease during any surgery requiring general anaesthesia.

Is Biochemical Follow Up Possible in Peripheral Arterial Disease Treatment: Hypoxia Inducible Factor-1 Alpha?

PURPOSE: The hypoxia inducible factor (HIF)-1 is a dimeric protein complex that plays an integral role in the body's response to hypoxia. This study aimed to analyze the regulation of HIF-1α following vascular and/or endovascular surgery in peripheral arterial disease (PAD) patients. MATERIALS AND METHODS: A total of 40 patients with PAD (≥Rutherford category 3) were included in this prospective study. The mean age was 61.9±9.2 years. Open surgery was performed in 16 patients, and endovascular intervention was performed in 34 patients. At preoperative (T1), postoperative day 1 (T2), and month 3 (T3), the serum HIF-1α levels were checked using the ELISA technique. RESULTS: At T3, the ankle-brachial index was significantly higher than the preoperative value (P<0.001). Serum HIF-1α levels at T1, T2, and T3 were 2.0±1.7 ng/mL, 1.9±1.7 ng/mL, and 1.6±1.4 ng/mL, respectively. Serum HIF-1α levels between T1 and T3 and between T2 and T3 were significantly different (P<0.05). The preoperative HIF-1α levels were lowest in iliac lesions compared to femoropopliteal or tibial lesions. CONCLUSION: The HIF-1α levels were decreased in all patients on postoperative days, T2 and T3, compared with the preoperative values. Our results indicated that HIF-1α may be a surrogate marker after revascularization in patients with PAD. Further studies are needed to analyze the sensitivity, specificity, and cut-off values of HIF-1α in patients with PAD.

Successful treatment of massive pulmonary embolism in a pregnant woman complicated with atypical hemolytic uremic syndrome.

The treatment of the massive pulmonary embolism concomitant hemodynamic instability in pregnancy is difficult and controversial and carries a high risk for both the baby and the mother. The catheter-directed thrombectomy with or without extracorporeal membrane oxygenation support may be a suitable management strategy in suitable cases but pregnancy-related complications may follow the treatment of pulmonary embolism and atypical hemolytic uremic syndrome should be considered in the differential diagnosis. We present a case of a 32-year-old patient who had a pulmonary embolism with shock in the 8th week of pregnancy complicated by atypical hemolytic uremic syndrome.

Validation of German Aortic Valve Score in a Multi-Surgeon Single Center.

OBJECTIVE:: Risk assessment for operative mortality is mandatory for all cardiac operations. For some operation types such as aortic valve repair, EuroSCORE II overestimates the mortality rate and a new scoring system (German AV score) has been developed for a more accurate assessment of operative risk. In this study, we aimed to validate German Aortic Valve Score in our clinic in patients undergoing isolated aortic valve replacement. METHODS:: A total of 35 patients who underwent isolated open aortic valve replacement between 2010 and 2013 were included. Patients with concomitant procedures and transcatheter aortic valve implantation were excluded. Patients' data were collected and analyzed retrospectively. Patients' risk scores EuroSCORE II were calculated online according to criteria described by EuroSCORE taskforce, Aortic Valve Scores were also calculated. RESULTS:: The mean age of patients was 61.14±13.25 years (range 29-80 years). The number of female patients was 14 (40%) and body mass index of 25 (71.43%) patients was in range of 22-35. Mean German Aortic Valve Score was 1.05±0.96 (min: 0 max: 4.98) and mean EuroSCORE was 2.30±2.60 (min: 0.62, max: 2.30). The Aortic Valve Score scale showed better discriminative capacity (AUC 0.647, 95% CI 0.439-0.854). The goodness of fit was x2HL=16.63; P=0.436). EuroSCORE II scale had shown less discriminative capacity (AUC 0.397, 95% CI 0.200-0.597). The goodness of fit was good for both scales. The goodness of fit was x2HL=30.10; P=0.610. CONCLUSION:: In conclusion, German AV score applies to our population with high predictive accuracy and goodness of fit.

Validation of german aortic valve score in a multi-surgeon single center

Abstract OBJECTIVE: Risk assessment for operative mortality is mandatory for all cardiac operations. For some operation types such as aortic valve repair, EuroSCORE II overestimates the mortality rate and a new scoring system (German AV score) has been developed for a more accurate assessment of operative risk. In this study, we aimed to validate German Aortic Valve Score in our clinic in patients undergoing isolated aortic valve replacement. METHODS: A total of 35 patients who underwent isolated open aortic valve replacement between 2010 and 2013 were included. Patients with concomitant procedures and transcatheter aortic valve implantation were excluded. Patients' data were collected and analyzed retrospectively. Patients' risk scores EuroSCORE II were calculated online according to criteria described by EuroSCORE taskforce, Aortic Valve Scores were also calculated. RESULTS: The mean age of patients was 61.14±13.25 years (range 29-80 years). The number of female patients was 14 (40%) and body mass index of 25 (71.43%) patients was in range of 22-35. Mean German Aortic Valve Score was 1.05±0.96 (min: 0 max: 4.98) and mean EuroSCORE was 2.30±2.60 (min: 0.62, max: 2.30). The Aortic Valve Score scale showed better discriminative capacity (AUC 0.647, 95% CI 0.439-0.854). The goodness of fit was x2HL=16.63; P=0.436). EuroSCORE II scale had shown less discriminative capacity (AUC 0.397, 95% CI 0.200-0.597). The goodness of fit was good for both scales. The goodness of fit was x2HL=30.10; P=0.610. CONCLUSION: In conclusion, German AV score applies to our population with high predictive accuracy and goodness of fit.

A new use of Fogarty catheter: chest tube clearance.

Chest tubes are commonly used for patients who have undergone a cardiothoracic procedure to avoid the complications related to the accumulation of blood and serous fluid in the chest. Although the traditional methods such as milking, stripping or active chest tube clearance devices are used to establish patency of the chest tubes, they can become clogged at any time after their placement. Our technique may re-establish the tube patency with utilising Fogarty catheter and without any detriment to tissues.

Impact of coronary collateral circulation and severity of coronary artery disease in the development of postoperative atrial fibrillation.

OBJECTIVES: Atrial fibrillation (AF) after cardiac surgery has been reported to be approximately 30%, making it one of the most important causes of morbidity and mortality post surgery. Although various clinical and laboratory predictors and underlying mechanisms progressing to postoperative AF have been proposed, the role of ischaemia in pathogenesis is doubtful. In this study, the association of coronary collateral circulation (CCC) and severity of coronary artery disease (CAD) with the development of postoperative AF was investigated. METHODS: A total of 597 patients who underwent on-pump coronary artery bypass surgery were included in the study. Pre-, peri- and postoperative variables were recorded in a computerized database. CCC and severity of CAD were documented for each patient according to Rentrop classification and Gensini score. RESULTS: Postoperative AF was observed in 96 patients (16.1%). Advanced age, female gender, presence of hypertension and low haematocrit level were significantly associated with postoperative AF. By contrast, CCC and severity of CAD were not associated with postoperative AF (P = 0.22 and 0.5, respectively). Older age and lower preoperative haematocrit levels were the major predictors of postoperative AF development in the multivariate regression analysis. CONCLUSIONS: CCC and severity of CAD did not have a significant effect on the occurrence of postoperative AF, suggesting an ineffective role of myocardial ischaemia in the development of this condition.

Time from cardiac catheterization to cardiac surgery: a risk factor for acute kidney injury?.

OBJECTIVES: Acute kidney injury can occur after cardiac catheterization and cardiac surgery. The negative effects of the contrast media and cardiopulmonary bypass on renal function may be additive when performed in close succession. The results in the literature are, however, conflicting. METHODS: Preoperative, operative, perioperative and postoperative variables of 573 consecutive adult patients who underwent cardiac surgery on cardiopulmonary bypass were collected prospectively. Acute kidney injury (AKI) was defined according to the Acute Kidney Injury Network criteria based on changes in serum creatinine level within 48 h of surgery. RESULTS: Acute kidney injury was detected in 233 patients (41%). In a multivariate analysis, older age (P = 0.01), longer cardiopulmonary bypass time (P = 0.003), lower preoperative haematocrit level (P = 0.02) and higher body mass index (P = 0.001) were found to be independently associated with development of acute kidney injury. Analysis of the time from cardiac catheterization to surgery by logistic regression modelling did not show any significant change in the risk of acute kidney injury. Risk related to time from catheterization to surgery was not increased even in the patients with elevated preprocedural creatinine levels (>106 µmol l(-1); P = 0.23), left ventricular dysfunction (ejection fraction <40%; P = 0.19) and older age (≥70 years; P = 0.86). CONCLUSIONS: The time from cardiac catheterization to cardiac surgery is not a risk factor for the development of postoperative acute kidney injury even in patients with other risk factors. Surgical intervention should not be delayed in emergency or urgent cases. The optimization of renal function seems to be the correct strategy in clinically stable patients with risk factors for acute kidney injury.

Double-layer pericardial patch for atrial septal defect closure.

After repair of atrial septal defects with or without patch, residual shunt, shrinkage, haemolysis and thromboembolic complications may occur. Even though the pericardium is quite a suitable material for the closure of atrial septal defects, the external surface of the pericardium is not smooth and may be a nidus for thrombus formation. We present a new technique to prevent these complications by using a folded, double-layer, durable pericardial patch without chemical pretreatment.

Popliteal artery pseudoaneurysm associated with solitary osteochondromatosis.

Osteochondroma is the most common benign tumor of the bone, seen mostly during adolescence. In the current study, we report a 19-year-old male patient with a two-week history of pain and swelling of the medial side of his right thigh just above the knee without any trauma. CT angiography revealed a popliteal artery pseudoaneurysm and its close relationship with a femoral osteochondroma. Surgical repair consisted of repair of pseudoaneurysm and removal of osteochondroma. In young patients, a non-traumatic pseudoaneurysm of distal femoral artery may be a complication of an osteochondroma and this treatable pathology should be looked for to prevent recurrence.

Left atrial leiomyosarcoma extending into the posterior mediastinum and mimicking a left atrial myxoma.

BACKGROUND: Intracardiac malignancies are extremely rare and hard to detect or differentiate preoperatively. CASE REPORT: We present a 48-year-old female patient who was diagnosed primarily with left atrial myxoma and taken into emergency surgery. The tumor extended into the pulmonary veins and infiltrated the atrial endocardium, and the histopathologic diagnosis was leiomyosarcoma. The left atrial endocardium was successfully peeled off with the tumor and complete resection was achieved. CONCLUSION: The possible malignant nature of intracardiac masses should be kept in mind, especially in middle-aged patients. The extent of the tumor must be determined in elective cases to establish the proper strategy for complete resection, which is the only chance of successful treatment for this lethal disease entity. Endocardial peeling is warranted for successful removal of the tumor mass in leiomyosarcoma.

Concomitant septal myectomy at the time of aortic valve replacement for severe aortic stenosis.

BACKGROUND: Left ventricular outflow tract obstruction may be unmasked after a successful aortic valve replacement (AVR) for severe aortic stenosis in the setting of asymmetrical basal septal hypertrophy (ABSH). The quantitative assessment of the obstructive potential of ABSH adjacent to a severely stenotic valve can be challenging. We reviewed our experience with patients who underwent concomitant septal myectomy at the time of AVR for severe aortic stenosis. METHODS: During the 10-year period ending January 2009, 3,523 patients underwent AVR for the primary indication of severe aortic stenosis. Forty-seven of these patients underwent concomitant septal myectomy. Preoperative and postoperative echocardiograms, operative data, hospital course, morbidity, and mortality were assessed. RESULTS: The mean age of the group was 73 +/- 11 years. The mean aortic valve area was 0.74 cm(2) preoperatively. On preoperative transthoracic echocardiography, only 28% of the patients were considered to be at risk for possible left ventricular outflow tract obstruction. The mean left ventricular mass index decreased from 113.7 +/- 24.3 g preoperatively to 90.0 +/- 17.2 g at 1 year after the surgery (p < 0.001). The operative mortality was 2%. Complete heart block was observed in 2 patients (4.2%), and no iatrogenic ventricular septal defect was noted. CONCLUSIONS: A quantitative assessment of the obstructive ABSH in the setting of severe aortic stenosis may be difficult preoperatively. Surgeons should inspect left ventricular outflow tract for possible obstructive ABSH at the time of AVR. Concomitant myectomy is a safe and effective procedure without additional complications and should be considered for patients with a preoperative or intraoperative diagnosis of ABSH even though dynamic obstruction was not demonstrated.

Concomitant surgery for renal neoplasm with pulmonary tumor embolism.

OBJECTIVE: Gross tumor pulmonary embolism from renal carcinoma is rarely diagnosed preoperatively. Individual cases of intraoperative embolization of tumor during radical resection of the kidney have been reported. We report on 9 patients who underwent pulmonary arterial tumor removal concomitant with nephrectomy. METHODS: Between 2000 and 2008, 9 patients underwent simultaneous nephrectomy and removal of gross embolic tumor from the pulmonary arteries. In 7 of these patients the diagnosis was made preoperatively by either computed tomography or magnetic resonance imaging. Cardiopulmonary bypass was used in all cases. Bilateral removal of pulmonary artery tumor was required in 7 patients and unilateral in 2. RESULTS: All patients survived to hospital discharge after a median stay of 8.8 days (mean, 6-17 days). Two patients are currently alive 4 and 56 months after the operation. Six patients died of distant metastasis or local recurrence of disease after 6, 9, 12, 17, 25, and 29 months. Actuarial survival at 6 months, 1, 2, and 3 years was 100%, 75%, 50%, and 25%, respectively. CONCLUSIONS: Pulmonary artery embolic tumor removal concomitant with nephrectomy for renal carcinoma can be performed safely. Survival of patients with combined surgery is comparable with that of patients with the same stage of renal neoplasm without pulmonary tumor embolism. The pulmonary tumor embolism in patients with renal carcinoma should be considered as extension of vena caval tumor but not as a distant metastasis. Pulmonary tumor removal provides symptomatic relief and may provide a survival benefit in these patients.

Geometric reconstruction of the sinus of Valsalva: utilization of the porcine aortic root.

Surgical repair of ruptured sinus of Valsalva aneurysm can be challenging, although it has been reported that mortality and morbidity is low. Distortion of sinus of Valsalva geometry can cause aortic valve regurgitation immediately or progressively after surgery. Maintenance of the appropriate geometry of sinus of Valsalva after resection of the aneurysm is critical in preserving the native aortic valve and its competency. Successful reconstruction with various patch materials such as Dacron patches (DuPont, Wilmington, DE) or pericardial patches has been reported. Nevertheless, the size and shape of patches used had to be created impromptu by surgeons without reliable methodology of reproducing the precise shape of the naturally occurring sinus of Valsalva. Herein, we report a successful repair of sinus of Valsalva aneurysm by utilizing a porcine sinus of Valsalva from a commercially available Freestyle valve (Medtronic Inc, Minneapolis, MN). We believe that this is a previously unreported technique.