Tradition or Innovation in Sternal Dehiscence Repair: Robicsek Versus Titanium Plate.

Objectives: Sternotomy is still the most commonly used incision in cardiac surgery. Sternal complications are seen at a rate of 0.5% to 6.1%. Sternal dehiscence increases morbidity and mortality after cardiac surgery. To prevent dehiscence, the search for alternative sternum closure methods continues today. Titanium plates produced for this purpose can also be used in patients who are re-operated due to sternal dehiscence. In our study, we investigated the effects of titanium plate repair and robicsek repair on the results in patients who were reoperated due to sternal dehiscence. Methods: Thirty-four patients who underwent reoperation due to sternal detachment in our hospital between September 2013 and December 2020 and had no signs of infection in the pre-operative period were analyzed retrospectively. The patients were divided into three groups according to the surgical method applied. These groups are as follows: Group 1: The cases in which the robicsek method was used, Group 2: the cases in which the titanium plate method was used, and Group 3: The cases where the robicsek + titanium plate methods were used together. Results: There was no significant difference between the groups in terms of basic demographic characteristics and risk factors, leading to sternal dehiscence. There was no significant difference between the groups in terms of mortality and length of hospital stay. Considering the infection rates in the post-operative period, 20% and 21.4% post-operative infections were detected in Group 1 and Group 3, respectively, while 70% post-operative infection was observed in Group 2, which was repaired only with the Robicsek technique (p<0.05). Conclusion: As supported by most studies in the literature, titanium plate application provides a superior sternum stabilization compared to the classical wire cerclage method. When evaluated in terms of cost-effectiveness, titanium plate method can be applied in high-risk patients in terms of sternal dehiscence.

Surgical results of chronic thromboembolic pulmonary endarterectomy in our recently developed program.

BACKGROUND: In this case series, we aimed to present our diagnostic workup, surgical management, and results of the patients who underwent pulmonary endarterectomy. METHODS: In this case series, a total of 26 patients (8 males, 18 females; median age: 58 years; range, 34 to 67 years) who were evaluated by a multidisciplinary team and were diagnosed with chronic thromboembolic pulmonary hypertension who underwent pulmonary endarterectomy in our clinic between November 2015 and December 2019 were included. Pulmonary endarterectomy procedure was performed in all cases under cardiopulmonary bypass and total circulatory arrest. The results of the procedures were analyzed retrospectively. RESULTS: Perioperative complications were observed in seven patients (26.9%) and in-hospital mortality rate caused by perioperative complications was 15.38%. At one-year of postoperative follow-up, the mean systolic pulmonary artery pressure decreased from 78±22 mmHg to 41±20 mmHg, pulmonary vascular resistance decreased from 698±10 dyn·s·cm-5 to 235±10 dyn·s·cm-5, 6-min walk distance increased from 345±10 m to 460±10 m and, arterial oxygen saturation increased from 85±3.5% to 95±4%. New York Heart Association functional class improvement from Class III-IV to Class I-II was observed in most patients, and one-year mortality rate was 19.23%. CONCLUSION: We suggest that patients diagnosed chronic thromboembolic pulmonary hypertension should be referred to cardiac surgery centers for pulmonary thromboendarterectomy, early before irreversible arteriopathy occurs.

Performance of the EuroSCORE II and the STS score for cardiac surgery in octogenarians.

BACKGROUND: We aimed to investigate the predictive value of Society of Thoracic Surgeons (STS) and European System for Cardiac Operative Risk Evaluation (EuroSCORE II) scores for mortality in octogenarian cardiac surgery patients. METHODS: Between January 2016 and December 2019, cardiac operations performed in 116 octogenarian patients (73 males, 43 females; mean age: 82.9±3.1 years; range, 80 to 97 years) were retrospectively analyzed. The patients with and without mortality were compared for their demographic and operative factors. The STS and EuroSCORE II scores, and observed mortality rates were assessed. RESULTS: Mean STS score was 3.7±11.1 and mean EuroSCORE II was 5.2±5.4. For any operation type, the mean EuroSCORE II was significantly higher (8.1±7.4 vs. 4.1±4.0, respectively; p=0.006) in the patients with mortality. For elective operations, the mean EuroSCORE II was higher in cases with mortality (7.2±7.3 vs. 3.7±3.9, respectively; p=0.006); however, for urgent cases, there was no significant difference between the scores. Using the receiver operating characteristic curve, the EuroSCORE II had a higher area under the curve for all cases and elective cases than the STS scores. CONCLUSION: The EuroSCORE II performed better than the STS score for mortality prediction in octogenarians, whereas the predictions of either scoring system was unsatisfactory for urgent surgery and combined procedures. Population-based validation studies are needed for a better risk scoring system in this age group.

Pressure-dimension index: A novel "morphologic-functional" index of right ventricle that predicts short-term survival after left ventricular assist device implantation.

BACKGROUND: Right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation is a major cause of postoperative morbidity and mortality. Despite the availability of multiple imaging parameters, none of these parameters had adequate predictive accuracy for post-LVAD RVF. AIM: To study whether right ventricular pressure-dimension index (PDI), which is a novel echocardiographic index that combines both morphologic and functional aspects of the right ventricle, is predictive of post-LVAD RVF and survival. METHODS: 49 cases that underwent elective LVAD implantation were retrospectively analyzed using data from an institutional registry. PDI was calculated by dividing systolic pulmonary artery pressure to the square of the right ventricular minor diameter. Cases were categorized according to tertiles. RESULTS: Patients within the highest PDI tertile (PDI>3.62 mmHg/cm2 ) had significantly higher short-term mortality (42.8%) and combined short-term mortality and severe RVF (50%) compared to other tertiles (P < .05 for both, log-rank p for survival to 15th day 0.014), but mortality was similar across tertiles in the long-term follow-up. PDI was an independent predictor of short-term mortality (HR:1.05-26.49, P = .031) and short-term composite of mortality and severe RVF (HR:1.37-38.87, P = .027). CONCLUSIONS: Increased PDI is a marker of an overburdened right ventricle. Heart failure patients with a high PDI are at risk for short-term mortality following LVAD implantation.

Risk factors for vasoplegia after coronary artery bypass and valve surgery.

INTRODUCTION: Vasoplegia denotes a state of low tissue perfusion characterized by hypotension, tachycardia, and low systemic vascular resistance. This state results in increased mortality and morbidity following cardiac surgery. A better understanding of the associated risk factors will guide the surgical team in patient management. The aim of this study is to determine which risk factors are involved in its emergence. METHODS: This prospective observational study included adult cardiac surgery patients between February - September 2018 at a single cardiothoracic surgery center. Patients were evaluated for cardiac contractility, surgical drainage, inotrope, and vasopressor requirement perioperatively. The groups were compared for demographic, echocardiographic, and operative variables. Variables significant in univariate analysis were carried on to binary logistic regression for risk factor analysis. RESULTS: A total of 31 patients were vasoplegic among a total of 487 included patients, resulting in a 6.37% incidence. In the vasoplegia group, chronic kidney failure, use of angiotensin-converting enzyme (ACE) inhibitors, use of angiotensin receptor blockers, and use of diuretics were more frequent, cardiopulmonary bypass (CPB) and aortic cross-clamp durations were longer, and mean Euroscore II was higher. Vasoplegia was more frequent in valve surgery and resternotomy patients. CPB duration, use of ACE inhibitors, use of angiotensin receptor blockers, and chronic renal failure were independent risk factors. CONCLUSION: Patients with long CPB duration, preoperative use of ACE inhibitors or Angiotensin receptor blockers, and a history of renal failure requiring dialysis are under increased risk of vasoplegia. Vasoplegia necessitates large-scale studies for a better understanding of its risk factors.

Critical limb ischemia patients clinically improving with medical treatment have lower neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios.

OBJECTIVES: Inflammation is a component in the pathogenesis of critical limb ischemia. We aimed to assess how inflammation affects response to treatment in patients treated for critical limb ischemia using neutrophil-to-lymphocyte (NLR) and platelet-to-lymphocytes ratios (PLR) as markers of inflammation. METHODS: Patients in a single tertiary cardiovascular center with critical limb ischemia unsuitable for surgical or interventional revascularization were retrospectively identified. Data were collected on medical history for risk factors, previous surgical or endovascular revascularization, and outcome. A standard regimen of low molecular weight heparin, aspirin, statins, iloprost infusions, and a standard pain medication protocol were applied to each patient per hospital protocol. Patients with improvement in ischemic pain and healed ulcers made up the responders group and cases with no worsening pain or ulcer size or progression to minor or major amputations made up the non-responders group. Responders and Non-responders were compared for risk factors including pretreatment NLR and PLR. RESULTS: 268 included patients who were not candidates for surgical or endovascular revascularization were identified. Responders had significantly lower pretreatment NLR (4.48 vs 8.47, p < 0.001) and PLR (162.19 vs 225.43, p = 0.001) values. After controlling for associated risk factors NLR ≥ 4.63 (p < 0.001) and PLR ≥ 151.24 (p = 0.016) were independently associated with no response to treatment. CONCLUSIONS: Neutrophil-to-lymphocyte ratio and platelet-to-lymphocytes ratio are markers of inflammation that are reduced in patients improving with medical treatment suggesting a decreased state of inflammation before treatment in responding patients.

Usefulness of right ventricular contraction pressure index to predict short-term mortality and right heart failure in patients who underwent continuous-flow left ventricular assist device implantation.

BACKGROUND: Right ventricular stroke work index is a useful but invasively measured parameter that can be used to predict right heart failure following continuous-flow left ventricular assist device implantation. Right ventricular contraction pressure index is a novel parameter that was developed to measure right ventricular stroke work index with echocardiography. We aimed to investigate the clinical usefulness of right ventricular contraction pressure index to predict short-term mortality and right heart failure in patients who underwent continuous-flow left ventricular assist device implantation. METHODS: A total of 49 patients who participated in institutional advanced heart failure registry and underwent continuous-flow left ventricular assist device implantation with a bridge-to-candidacy indication were analyzed retrospectively. Right ventricular contraction pressure index was calculated using offline measurements. Demographic, clinical and outcome data were obtained from the registry data. Patients were grouped according to right ventricular contraction pressure index quartiles. RESULTS: Patients within the lowest right ventricular contraction pressure index quartile had a trend toward higher short-term mortality (46.2%, p = 0.056) and combined short-term mortality and definitive right heart failure (53.8%, p = 0.054) at 15th day postoperatively. Similarly, short-term survival or survival free of definite right heart failure were significantly lower in the lowest right ventricular contraction pressure index quartile (log-rank p = 0.045 and log-rank p = 0.03, respectively). In a proportional hazards model that included echocardiographic parameters, right ventricular contraction pressure index was an independent predictor for short-term mortality (odds ratio: 6.777, 95% confidence interval: 1.118-41.098, p = 0.037), but not for combined short-term mortality and definite right heart failure. No such associations were found for long-term mortality. Right ventricular contraction pressure index had a statistically significant correlation with invasively measured pulmonary capillary wedge pressure, pulmonary vascular resistance, mean pulmonary pressure, and right ventricular stroke work index. CONCLUSION: Right ventricular contraction pressure index was found as a useful parameter for determining short-term postoperative mortality in patients undergoing continuous-flow left ventricular assist device implantation.

The neutrophil-lymphocyte ratio and the platelet-lymphocyte ratio correlate with thrombus burden in deep venous thrombosis.

OBJECTIVE: Deep venous thrombosis (DVT) is associated with a state of increased inflammation at the time of diagnosis as either a cause or consequence. The neutrophil-lymphocyte ratio (NLR) and the platelet-lymphocyte ratio (PLR) are easy-to-obtain, low-cost biomarkers of systemic inflammation. The objective of this study was to determine whether these two ratios at the time of diagnosis can be an indicator of thrombus burden in terms of thrombus location in DVT. METHODS: Patients with a diagnosis of DVT confirmed with venous Doppler ultrasound in a single referral center for cardiovascular diseases between 2014 and 2018 were retrospectively analyzed. Of 1852 patients, 933 with blood counts at time of diagnosis were included. The NLR and PLR were calculated from blood count results. Patients were categorized according to the level of thrombus and the number of vein segments involved as evidenced by Doppler ultrasound findings. RESULTS: Iliac, femoral, popliteal, and crural groups had a mean NLR of 5.07, 4.18, 3.59, and 3.24, respectively (P = .002), and a mean PLR of 1.82 × 107, 1.76 × 107, 1.47 × 107, and 1.64 × 107, respectively (P = .011). Patients with proximal DVT had a higher mean NLR (4.40 ± 4.28 vs 3.54 ± 3.55; P = .05) and PLR (1.77 × 107 ± 1.3 × 107 vs 1.49 × 107 ± 1.08 × 107; P = .03) than patients with distal DVT. NLR increased with the number of vein segments involved (P = .001), but this correlation did not exist with PLR (P = .097). CONCLUSIONS: A state of inflammation, demonstrated by NLR and PLR, at the time of diagnosis in DVT patients correlates with disease burden in terms of thrombus location. Further studies are required to assess the clinical value of NLR and PLR at the bedside.

The role of SYNTAX score in decision-making for preoperative carotid artery screening in patients undergoing coronary artery bypass surgery.

BACKGROUND: The coexistence of coronary artery disease (CAD) in patients undergoing coronary artery bypass surgery (CABG) is a risk factor for stroke and death. The aim of this study is to evaluate the potential of the SYNTAX score (SXscore) for predicting carotid stenosis in patients undergoing CABG. METHODS: We retrospectively reviewed 291 patients (225 males, mean age 60.5 ± 8.5 years) who underwent CABG in a single center in 2014 and were screened for carotid artery preoperatively. The total SXscore was obtained by scoring every luminal narrowing greater than 50% in coronary vessels larger than 1.5 mm using the SXscore algorithm. Correlations between the severity of carotid stenosis and SXscore were analyzed. RESULTS: As the degree of carotid artery stenosis increases (≤%50; ≥%50 vs ≥%70), the mean SXscore (19.06 ± 7.72, P > 0,05; 28.40 ± 6.89, P < 0,01; 31.02 ± 7.04, P < 0.01, respectively) were found to increase. Receiver operating characteristic analysis revealed a cut-off point of 27 or more in SXscore according to the presence of carotid stenosis greater than or equal to %70. The risk of existence of significant carotid stenosis was 58-fold greater in cases with SXscore greater than or equal to 27. In cases with SXscore greater than or equal to 27, the risk of existence of significant carotid stenosis was 58-fold greater with a confidence interval of 95%. Moreover, the presence of left main CAD was associated with the severity of carotid stenosis (<50% carotid stenosis, P > 0.05; ≥%50, P = 0.001; and ≥70, P = 0.001). CONCLUSION: This study suggests that the presence of left main coronary artery disease or SXscore greater than or equal to 27 should require preoperative carotid screening in patients undergoing CABG, regardless of the presence of risk factors.

The importance of mass diameter in decision-making for preoperative coronary angiography in myxoma patients.

OBJECTIVES: Although coronary angiography (CAG) is generally performed to rule out coexisting coronary artery disease in patients with cardiac myxoma, its necessity to evaluate vascular supply of the myxoma is debatable. The aim of this article is to evaluate clinical experience and CAG findings in our patient group. METHODS: This retrospective analysis was performed in 46 patients (17 men, mean age 57.7 ± 8.6 years), who underwent surgery with an indication for cardiac myxoma between 2004 and 2016 with a CAG performed preoperatively. All CAGs were evaluated in a blinded manner by a cardiac surgeon and a cardiologist separately. Correlations between the presence and pattern of feeding vessels, presence of an arteriocavity fistula (ACF), coronary arterial dominance, size of mass and clinical presentations were analysed. RESULTS: Coronary artery disease defined as >50% obstructive lesions was detected in 10 patients (21.7%). The tumour diameter was found to be significantly higher in patients who had an ACF and a dual-feeding artery (P = 0.049 and P = 0.0001, respectively). Additionally, there was a significant relationship between the presence of dual-feeding vessels and ACF (P = 0.014). ROC analysis revealed a cut-off point of 27 mm in diameter based on the presence of an ACF and a dual-feeding artery. In cases with a diameter of 27 mm or above, the risk of existence of an ACF was 4.68-fold greater, with a confidence interval of 95%, and a dual-feeding pattern was seen in all of them. CONCLUSIONS: This study suggests that preoperative CAG can be considered to detect feeding vessels that may lead to a steal phenomenon, which may alter the management in patients with myxoma greater than 27 mm in diameter.

Retrospective cohort study for evaluating the INR monitoring patterns in patients with deep vein thrombosis in daily practice: Analysis of 2010-2013 database of a tertiary care center.

OBJECTIVE: To evaluate the international normalized ratio (INR) monitoring patterns in patients with deep vein thrombosis. METHODS: Of 32,012 patients with ≥1 outpatient INR measurement and 42,582 patients with confirmed deep vein thrombosis diagnosis registered to our hospital between 1 January 2010 and 31 December 2013, 6720 records were identified to have both deep vein thrombosis and international normalized ratio measurement, and 4.377 out of 6.720 single patient records were determined to be statistically analyzable. RESULTS: Median INR measurement frequency was 6.47 times/year and patients had INR levels of 2-3 in 34.3% of follow-up time. Having ≥70% vs. <70% of follow-up time within therapeutic range was associated with lower hospital admission frequency (9.7 vs. 10.3 times/year). CONCLUSION: Our study revealed only one-third of the follow-up time to be spent within therapeutic INR, association of INR therapeutic range with lesser number of hospital admissions and INR monitoring frequency of 6.47 times/year despite lack of stable INR control in most of the deep vein thrombosis patients.

Neutrophil-to-lymphocyte ratio for early renal failure under extracorporeal membrane oxygenation support for postcardiotomy shock.

BACKGROUND: This study aims to investigate the relationship between the neutrophil-to-lymphocyte ratio and renal injury in patients under extracorporeal membrane oxygenation support for postcardiotomy shock. METHODS: Between January 2007 and July 2018, a total of 119 patients (38 males, 81 females; mean age 54.4±13.0 years; range, 24 to 74 years) who received extracorporeal membrane oxygenation support for postcardiotomy shock and survived at least 48 hours in our center were retrospectively analyzed. Pre- and postoperative neutrophil-to-lymphocyte ratios, demographic characteristics, renal function parameters, and extracorporeal membrane oxygenationrelated data of the patients were recorded. Occurrence and stages of renal injury was determined using the revised Acute Kidney Injury Network and Kidney Disease Improving Global Outcomes criteria. RESULTS: No significant relationship was found between preoperative neutrophil-to-lymphocyte ratio and renal injury (p>0.05). Postoperative neutrophil-to-lymphocyte ratio was higher in patients who developed renal injury, compared to patients without renal injury (8.68 [0.84-42.00] vs. 4.02 [1.04-21.21], respectively, p=0.004). When patients were grouped for renal injury stage according to the revised Acute Kidney Injury Network (p=0.015) and Kidney Disease Improving Global Outcomes (p=0.006) criteria, the patients with more severe renal injury had higher neutrophil-to-lymphocyte ratio. The receiver operating characteristics analysis revealed a cut-off value of 6.71 for the neutrophil-to-lymphocyte ratio for the detection of renal injury. Patients with a value above 6.71 had an odds ratio of 5.941 for occurrence of renal injury. CONCLUSION: Postoperative, but not preoperative neutrophil-tolymphocyte ratio is associated with presence and severity of renal injury in patients under extracorporeal membrane oxygenation support for postcardiotomy shock. Neutrophil-to-lymphocyte ratio is a simple and inexpensive marker of inflammation in this patient population.

Early and late results in surgical excision of primary cardiac tumors: Our single-institution experience.

BACKGROUND: In the present study, we present our experience for surgical excision for cardiac masses and to analyze survival characteristics of these patients. METHODS: Between January 2004 and December 2015, a total of 131 patients (88 females, 43 males; mean age 49.4±16.2 years; range, 1.2 months to 81 years) with primary cardiac tumors who underwent surgery in our center were included in this study. Demographic and other patient-related data were retrospectively reviewed from medical records of our center. RESULTS: All benign tumors were completely resected, whereas only palliative procedures were performed for malignant tumors. Pathology results revealed 88.5% (n=116) benign and 11.5% (n=15) malignant tumors. Tumors were most frequently located in the left atrium (76.3%, n=100), followed by the right atrium (11.5%, n=15), and the right ventricle (5.3%, n=7). Among all patients, 116 (88.5%) survived, while late mortality was seen in 15 patients (11.5%). The mean survival was 130.6±4.5 months. The latest mortality was observed at 124 months, whereby the cumulative survival rate was 79.2%. There was a statistically significant relationship between mortality and pathological characteristics of the tumor, and malignant cases had significantly higher mortality rates (p=0.002). CONCLUSION: Surgical resection of primary cardiac tumors can be performed with low morbidity and mortality rates. Although survival rates in benign tumors are satisfactory, patients with malignant tumors have poor prognosis. The main clinical predic.

Exceptional cause of chest pain: idiopathic ascending aortitis.

Idiopathic ascending aortitis is an insidious disease most often encountered during an evaluation for other cardiovascular and connective tissue diseases. To the best of our knowledge, admission to an emergency department with chest pain due to idiopathic ascending aortitis has not been reported before. Herein, the case of a 46-year-old man with chest and back pain symptoms that were discovered to be secondary solely to idiopathic ascending aortitis is described.