Low-Dose Heparin Protocol in Type A Aortic Dissection Surgeries.

OBJECTIVE: We aim to compare the heparin dose regimen in terms of bleeding, reoperation rate due to severe bleeding, and the amount of transfusion of the blood products in patients who underwent surgery for type A aortic dissection (TAAD). MATERIALS AND METHODS: Between January 2018 and August 2021, 90 adult patients who underwent for TAAD were included. Primary outcome measures were postoperative bleeding amount and blood product transfusion requirements. Two different protocols performed in TAAD surgery in our clinic. In this pre- and postimplementation study, before October 2019, the standard-dose heparin protocol (SH group) was used and after November 2019, the low-dose heparin protocol (LH group) was used and two groups were compared. Mechanical ventilation duration, length of intensive care unit and hospital stay, postoperative drainage volumes, blood product transfusions, reoperations due to bleeding, and in-hospital mortality rates were recorded. RESULTS: The dosages of heparin and activated clotting time values, as well as the additional heparin requirement, were significantly different between the two groups (p < 0.001). Standard-dose heparinization was needed only in 33.3% of patients in the LH group. In the SH group, postoperative total drainage and red blood cell (RBC) transfusion were significantly higher than the LH group (p = 0.036 and p = 0.046, respectively). CONCLUSION: We found that the low-dose heparin regimen resulted in significantly less postoperative total drainage and RBC transfusion requirement in patients who underwent for TAAD.

The role of the preoperative screening of sleep apnoea by Berlin Questionnaire and Epworth Sleepiness Scale for postoperative atrial fibrillation.

BACKGROUND: Undiagnosed obstructive sleep apnoea (OSA) is a risk factor for postoperative atrial fibrillation (POAF) as well as for heart disease in general. This necessitates screening during preoperative assessment to facilitate the implementation of strategies to minimise the postoperative risk. Overnight polysomnography is the "gold standard" for the diagnosis of OSA but may be impractical during preoperative assessment, and so questionnaires may be useful for screening OSA. The Berlin Questionnaire (BQ) and Epworth Sleepiness Scale (ESS) are two of the widely prescreening tools for persons who may suffer from sleep disorders. Thus, screening for and treating OSA as part of the routine preoperative evaluation of cardiac surgical patients may be a useful strategy for preventing POAF. OBJECTIVE: We investigated whether there is an association between POAF and sleep disorders evaluated by the BQ and ESS in this settings. METHODS: In 73 consecutive patients undergoing CABG with cardiopulmonary bypass, preoperative clinical characteristics and operational data were examined. During the clinical evaluation, all patients answered the ESS and BQ voluntarily upon admission. Patients were continuously monitored for the occurrence of sustained postoperative AF while hospitalised. RESULTS: There were 33 patients with POAF and 40 patients without POAF as age- and gender-matched controls. The prevalence of high score in ESS was higher in POAF group compared to control group (52% vs 27%; p: 0.030). There was a higher prevalence of high risk for OSA in BQ in the POAF group (58% vs 34%; p: 0.044). CONCLUSION: Preoperative questionnaire-based diagnosis of OSA by the simple BQ and ESS may be useful in predicting POAF, and can be easily incorporated into routine screening of surgical patients undergoing CABG operation.

Should we touch tricuspid valve at the time of LVAD implantation? A young patient series.

BACKGROUND: The aim of the study is to compare the results of patients who had moderate or severe tricuspid insufficiency (TI) at the time of left ventricular assist device (LVAD) implantation that did not undergo intervention. METHODS: Between October 2013 and December 2019, 144 patients who did not undergo tricuspid valve repair (TVR) during LVAD implantation in our department were included in the study. The patients were divided into two groups according to the TI grade; Group 1: 106 patients (73.6%) with moderate TI and Group 2: 38 patients (26.4%) with severe TI. All patients were evaluated for mortality, need of inotrope, blood product transfusion, intensive care unit (ICU) stay, duration of mechanical ventilation, and early and late right ventricular failure (RVF). Minimally invasive technique was favored in patients with worse right ventricular (RV) function to prevent the need for postoperative RV support and bleeding. RESULTS: The mean ages of the patients in the Group 1 and Group 2 were 46 ± 15 years (82% male), and 45 ± 11.2 years (81.5% males), respectively. Post-operative duration of mechanical ventilation, ICU stay, blood loss, and reoperations were similar (p > 0.05). There was no significant difference in early RVF, pump thrombosis, stroke, bleeding, and 30-day mortality between groups (p > 0.05). Incidence of late RVF was higher in Group 2 (p < 0.05). CONCLUSION: Although the risk of late RVF may increase in patients with preoperative severe TI, not intervening in TI during LVAD implantation does not cause adverse clinical outcomes in the early period.

CoronaVac, BNT162b2 and heterologous COVID-19 vaccine outcomes in patients with ventricular assist device.

BACKGROUND: A consensus has not yet been reached regarding which COVID-19 vaccine program should be applied in patients with ventricular assist device (VAD). Our aim was to assess the clinical outcome of inactivated, mRNA and heterologous vaccine program in patient with VAD. METHODS: In this retrospective and cross-sectional study; adult patients who underwent VAD implantation between January 2012 and September 2021 and received any vaccine that were used in Republic of Türkiye for COVID-19, were included. The patients were divided into three groups according to the type of vaccine; "inactivated," "mRNA" and "heterologous." Clinical outcomes were analyzed. RESULTS: Eighteen patients were in each group in the "inactivated," "mRNA" and "heterologous" groups. Mean age was 51.6 ± 12 years in "inactivated" group, 42.5 ± 15.5 years in "mRNA" group and 41.1 ± 15.4 years in "heterologous" group. There was no significant difference between the groups in age, gender, body surface area, body mass index and etiology (p > 0.05). After last dose of vaccines, the number of patients had COVID-19 positive test were three (16.7%), one (5.6%), and two (11.1%) in "inactivated," "mRNA" and "heterologous" groups, respectively. Pump thrombosis was seen in two patients in "mRNA" group and one patient in "heterologous" group. No pump thrombosis was seen in "inactivated" group. COVID-19-related death or intubation was not observed. CONCLUSION: All vaccine that used for COVID-19 are safe and effective in patients with VAD. In countries that give priority to inactivated vaccines, mRNA vaccines may then be made as boosters.

Implantable cardioverter defibrillator lead endocarditis causing diffuse right atrial abscess and pulmonary artery embolism.

Implantation of electrophysiological cardiac devices such as pacemakers and implantable cardioverter defibrillators has become a widely available and routine procedure in cardiovascular medicine. One of the most feared complications of device implementation is infection. Infection rates for these devices are reported to vary between 0.7% and 7.0%. Cardiac thromboembolic event is a recognized complication of permanent cardiac rhythm devices with an incidence of 0.6%-3.5%, unrelated to lead size or number. These complications are associated with high morbidity and mortality rates. In this case report, right atrial mass, right atrial abscess, perforation of tricuspid septal leaflet, and pulmonary embolism secondary to ICD lead endocarditis is presented.

What factors counteract mid-term survival following endovascular repair of abdominal aortic aneurysms?

INTRODUCTION: Endovascular aortic aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) is increasingly used, and has become the standard treatment option for AAA. AIM: To evaluate the outcomes and predictors of survival of endovascular treatment of AAA in the short- and medium-term. MATERIAL AND METHODS: A total of 222 patients having endovascular AAA repair between January 2013 and December 2019 by the same surgical team were included in the study. Patient demographics, perioperative and follow-up data including mortality, complications, and need for secondary intervention were collected. The primary endpoint was all-cause mortality. Kaplan-Meier analysis was conducted for survival and Cox regression models were assessed for predictors of survival. RESULTS: The median age was 70 years, with male predominance (202 patients, 91%). Thirty-day mortality was 1.8%. Median follow-up to the primary endpoint was 20 months (range: 1-80 months). Survival rates at 1, 3, and 5 years were 93.5%, 81.4%, and 62.2%, respectively. Freedom from secondary intervention rates were 95.5% at 1 year, 88.7% at 3 years, and 82.1% at 5 years. Cox proportional hazard models showed that preoperative creatinine levels ≥ 1.8 mg/dl (hazard ratio (HR) = 2.68, 95% CI: 1.21-6.42, p = 0.027), haemoglobin levels < 10 gr/dl (HR = 3.38, 95% CI: 1.16-9.90, p = 0.026), ejection fraction < 30% (HR = 5.67, 95% CI: 1.29-24.86, p = 0.021), and AAA diameter ≥ 6.0 cm (HR = 2.20, 95% CI: 1.01-4.81, p = 0.049) were independently associated with mid-term survival. CONCLUSIONS: EVAR is a safe procedure with low postoperative morbidity and mortality. This study confirms that the mid-term survival and results are favourable. However, the analysed factors in this study that predict reduced survival (high preoperative creatinine, low haemoglobin, low ejection fraction and larger aneurysms) should be judged when planning endovascular repair of AAA.

Early and long-term results of heart transplantation with reoperative sternotomy.

BACKGROUND: This study aims to investigate the effects of reoperative sternotomy on early and long-term outcomes after heart transplantation. METHODS: We retrospectively reviewed data of a total of 92 patients (72 males, 20 females; mean age 36 years; range, 3 to 61 years) who underwent orthotopic heart transplantation between May 1998 and July 2014. The patients were divided into three groups. Group A (n=23) included patients who underwent previous cardiac surgery with sternotomy other than ventricular assist device implantation; Group B (n=12) included patients who were bridged-to-transplant with a ventricular assist device; and Group C (n=57) included patients who for the first time underwent heart transplantation without previous sternotomy. Preoperative and operative data of the three groups were compared. The short- and long-term outcomes of all groups were analyzed. RESULTS: There was no significant difference among the groups, except for the age and preoperative international normalized ratio. Total ischemia time in the ventricular assist device group was longer than Group C. The length of intensive care unit stay was also longer in the ventricular assist device group than the other groups. The amount of postoperative chest tube drainage and blood transfusion was higher in Group A. Early mortality rate was significantly higher in Group A. There was no significant difference in survival among the three groups in the long-term. According to the logistic regression analysis, no variable was found to be a significant risk factor for mortality. CONCLUSION: Reoperative sternotomy other than ventricular assist device implantation was found to be a risk factor for early mortality; however, mid and long-term survival rates were similar to patients in whom transplantation was the primary procedure. In patients with reoperative sternotomy, heart transplantation can be performed with similar risks to patients without resternotomy with careful selection and accurate pre- and intraoperative surgical approach.

Building a patient blood management program in a large-volume tertiary hospital setting: Problems and solutions.

Successful implementation of a patient blood management program necessitates the collaboration of a strong organization and a multidisciplinary approach. We organized a meeting with broad participation in our center to establish a consensus for implementation of a specific patient blood management program. International and domestic experiences were shared, the importance of coordination and execution of different pillars in patient blood management were discussed, and the problems about the blood transfusion system were also investigated with the proposal for solutions. The data obtained from this meeting are presented to be a guide for similar large-volume tertiary hospitals for integration of a patient blood management protocol.

Consensus Report on Diagnosis, Treatment and Prevention of Infective Endocarditis by Turkish Society of Cardiovascular Surgery (TSCVS), Turkish Society of Clinical Microbiology and Infectious Diseases (KLIMIK), Turkish Society of Cardiology (TSC), Turkish Society of Nuclear Medicine (TSNM), Turkish Society of Radiology (TSR), Turkish Dental Association (TDA) and Federation of Turkish Pathology Societies (TURKPATH) Cardiovascular System Study Group.

Infective endocarditis (IE) is rare, but associated with significant morbidity and mortality rates. Estimates of the incidence of IE in Turkey are compromised by the absence of population-based prospective studies. Due to the frequent presence of predisposing cardiac conditions and higher rates of nosocomial bacteremia in highrisk groups, the incidence of IE is expected to be higher in Turkey. Additionally, while IE generally affects older people in developed countries, it still affects young people in Turkey. In order to reduce the mortality and morbidity, it is critical to diagnose the IE to determine the causative agent and to start treatment rapidly. However, most of the patients cannot be diagnosed in their first visits, about half of them can be diagnosed after three months, and the disease often goes unnoticed. In patients diagnosed with IE, the rate of identification of causative organisms is significantly lower in Turkey than in developed countries. Furthermore, most of the centers do not perform some essential microbiological diagnostic tests as a routine practice. Some antimicrobials that are recommended as the first-line of treatment for IE, particularly antistaphylococcal penicillins, are not available in Turkey. These problems necessitate reviewing the epidemiological, laboratory, and clinical characteristics of IE in our country, as well as the current information about its diagnosis, treatment, and prevention together with local data. Physicians can follow patients with IE in many specialties. Diagnosis and treatment processes of IE should be standardized at every stage so that management of IE, a setting in which many physicians are involved, can always be in line with current recommendations. Study Group for Infective Endocarditis and Other Cardiovascular Infections of the Turkish Society of Clinical Microbiology and Infectious Diseases has called for collaboration of the relevant specialist organizations to establish a consensus report on the diagnosis, treatment, and prevention of IE in the light of current information and local data in Turkey.

Open heart surgery in patients with end-stage renal failure: fifteen-year experience.

OBJECTIVE: Risk factors and results of cardiac surgery with cardiopulmonary bypass (CPB) in hemodialysis-dependent renal failure patients at our center were evaluated. METHODS: Out of 16,425 patients undergoing open heart surgery with CPB at our center between January 1991 and April 2006, 91 (0.6%) experienced hemodialysis-dependent end-stage renal failure. Preoperative, operative, and postoperative findings of two groups of patients were evaluated: those with normal renal function (control group) and those with chronic renal failure undergoing regular hemodialysis (HDRF group). Survival analyses of the hemodialysis group of patients were performed. RESULTS: In the hemodialysis group, 54 (59.3%) patients underwent coronary artery surgery, 31 (34.1%) patients had valve surgery, four (4.4%) patients had aortic surgery, and two others (2.2%) experienced concomitant coronary and peripheral artery surgery. CPB and aortic cross-clamping (ACC) times were longer in the HDRF group (p=0.000 and 0.002, respectively). There was no significant difference between the two groups with regard to either reoperations, infections, pulmonary and gastrointestinal system complications, or cerebrovascular event parameters (p=0.167, 0.341, 1.000, 1.000, and 1.000, respectively). There was no difference between groups in the postoperative development of low cardiac output (p=0.398). The early mortality rate was 7.7% (seven patients) in the HDRF group and 4.8% (780 patients) in the controls (p=0.211). The actuarial survival rates in HDRF survivors at one, two, three, four, five, and ten years were overall 86%, 80%, 68.1%, 45.4%, 20%, and 6.8%, respectively. CONCLUSIONS: Open heart surgery in hemodialysis patients is associated with a higher incidence of risks, but can be performed with acceptable operative complications and mortality with an effective hemodialysis program.

Late atrioventricular block and permanent pacemaker implantation after heart transplantation.

The need for permanent pacemaker implantation due to late atrioventricular (AV) block after heart transplantation is rare. A 59-year-old male patient underwent heart transplantation. He presented with syncope eight months after transplantation. Ambulatory 24-hour Holter monitoring showed predominant sinus rhythm with a mean heart rate of 74 bpm, intermittent second-degree AV block, and high-degree AV block with pauses of up to 10.6 seconds. Percutaneous transvenous endomyocardial biopsy yielded a histologic diagnosis of grade IA rejection according to the ISHLT (International Society of Heart and Lung Transplantation) scoring system. A permanent pacemaker with DDD-R mode was implanted via the left subclavian vein, and he was discharged on the following day without any complication.

Perioperative planning for cardiovascular operations in the COVID-19 pandemic.

Coronavirus disease-2019 (COVID-19) is a serious health concern which alert all healthcare professionals worldwide. There are two main issues caused by this pandemic regarding for the healthcare system. First, it is a necessity to postpone many elective procedures/surgeries to reduce the burden of the healthcare system which may be confronted with strain by the increased speed of transmission. Therefore, we aimed to develop an algorithm called as Level of Priority to identify the priority and deferrability of cardiovascular diseases requiring surgery. Second, it is essential to perform surgery and intensive care unit follow-up in a setting where the infection prevention measures are followed for primary patients requiring emergency cardiovascular surgery. In this article, we present necessary precautions to be exercised to provide the patient safety and the highest level of protection for the surgical team.

[Effects of combined mitral valve replacement and radiofrequency atrial ablation in chronic atrial fibrillation]. / Kronik atriyal fibrilasyonda mekanik mitral kapak replasmani ile birlikte radyofrekans atriyal ablasyonun etkinligi.

OBJECTIVE: The aim of the study is to find out the efficacy of radiofrequency catheter atrial ablation (RF) simultaneously done with mitral valve replacement (MVR) surgery in patients having rheumatic mitral valve disease with chronic atrial fibrillation and to evaluate the short-term postoperative results. METHODS: Seventeen patients underwent MVR surgery, and intraoperative RF procedures were done simultaneously with MVR to eight of these patients, whereas remaining nine of them were assigned to control group. Patients were assessed preoperatively, at time of discharge, and 1st, 6th and 12th months controls. Atrial and ventricular functions were evaluated with echocardiography, serum atrial natriuretic peptide (ANP) levels were investigated and electrocardiograms were recorded in all patients. RESULTS: Demographically there were no significant differences between two groups. Radiofrequency ablation group had longer aortic cross-clamping and cardiopulmonary bypass times. Sinus rhythm was established in seven patients of RF group at postoperative 12th month. However, all patients of this group experienced sinus rhythm at postoperative sixth month whereas 'atrial kick' was detected in five of them. Significantly increased ejection fraction, decreased pulmonary artery pressure and decreased left atrial diameter were observed in RF group compared to control group. Serum ANP levels were found to be significantly decreased as compared to preoperative periods in both groups. CONCLUSION: Although RF ablation has higher costs, this technique is efficient and useful to restore the sinus rhythm and to recover the atrial functions back in patients having rheumatic mitral valve disease.

Low-Dose Valacyclovir for Cytomegalovirus Infection Prophylaxis After a Heart Transplant.

OBJECTIVES: Cytomegalovirus infection is a major cause of morbidity and mortality in solid-organ transplant. Low doses of valacyclovir have been administered as cytomegalovirus prophylaxis in our institution for years. To the best of our knowledge, there is no published study of a low-dose regimen for cytomegalovirus prophylaxis in heart transplant patients. Therefore, our aim was to determine the results of low doses of valacyclovir in heart transplant. MATERIALS AND METHODS: Between September 2006 and December 2014, sixty-eight patients underwent orthotopic heart transplants. All of the patients received triple immunosuppressive therapy after surgery. During the next 6 months, sulfamethoxazole/trimethoprim was administered for Pneumocystis jiroveci pneumonia, and toxoplasmosis. Additionally all patients received valacyclovir hydrochloride (1000 mg/d, oral) for cytomegalovirus prophylaxis and nystatin oral rinse for prophylaxis of fungal infections. RESULTS: There was only 1 cytomegalovirus infection at follow-up. The patient had cytomegalovirus pneumonia at 17-month follow-up. In response to treatment with 1-week intravenous ganciclovir, the patient was discharged with a further 6-month oral valacyclovir therapy (1000 mg/d). CONCLUSIONS: In this study, we hypothesized that daily use of low-dose valacyclovir (1000 mg/d) is not only sufficient for cytomegalovirus prophylaxis but also beneficial in terms of cost.

Arch repair with unilateral antegrade cerebral perfusion.

OBJECTIVE: Several antegrade cerebral perfusion techniques with differing neurological outcomes are employed for aortic arch repair. This study demonstrates the clinical results of aortic arch repair with unilateral cerebral perfusion via the right brachial artery. METHODS: Between January 1996 and March 2004, 181 patients underwent aortic arch repair via the right upper brachial artery with the use of low-flow (8-10 ml/kg per min) antegrade selective cerebral perfusion under moderate hypothermia (26 degrees C). Mean patient age was 58+/-12 years. Presenting pathologies were Stanford type A aortic dissection in 112, aneurysm of ascending and arch of aorta in 67, and isolated arch aneurysm in two patients. Ascending and/or partial arch replacement was performed in 90 patients and ascending and total arch replacement in 91 patients (including 27 with elephant trunk). In a subset of patients, renal and hepatic effects of ischemic insult were assessed. Free hemoglobin and lactate dehydrogenase levels were measured pre and postoperatively to identify hemolytic effects of brachial artery cannulation. RESULTS: Mean antegrade cerebral perfusion time was 36+/-27 min. Three patients with acute proximal dissection died due to cerebral complications. One patient had transient right hemiparesis. Total major neurological event rate was 2.2%. Brachial artery was able to carry full cardiopulmonary bypass flow with mild hemolysis. Renal and hepatic tests showed no deleterious effects of limited ischemia at moderate hypothermia. CONCLUSIONS: Arch repair with antegrade cerebral perfusion through right brachial artery has excellent neurological results, provides technical simplicity and optimal repair without time restraints, does not necessitate deep hypothermia and requires shorter CPB and operation times.

Paracardiac gossypiboma (textiloma) in 2 patients.

Gossypiboma, also called textiloma, results when a cotton matrix such as a gauze pad or surgical sponge is left in a body cavity after surgery. The diagnosis of gossypiboma can be challenging. In symptomatic patients, operative removal of the pad or sponge is recommended; however, the decision to operate might be less immediately clear in asymptomatic patients. We report the cases of 2 patients in whom we diagnosed paracardiac gossypiboma. In addition, we briefly review other cases and discuss the treatment of asymptomatic patients.

Aortic arch repair with right brachial artery perfusion.

BACKGROUND: To determine the effectiveness of unilateral selective cerebral perfusion for aortic arch repair and to discuss possible modifications to enhance technical simplicity. METHODS: In the period between January 1996 and April 2001, 104 patients underwent aortic arch repair with the use of right brachial artery low flow (8 to 10 mL/kg per minute) antegrade selective cerebral perfusion under moderate hypothermia (26 degrees C). Mean patient age was 52 +/- 12 years. Sixty-four patients presented with Stanford type A aortic dissection, including 12 with acute dissection; 38 patients had aneurysmal dilatation of the ascending aorta and aortic arch; and 2 patients had isolated arch aneurysm. Ascending and partial arch replacement was performed in 50 patients; ascending and total arch replacement in 33 patients; ascending and descending arch replacement in 19 patients; and isolated arch replacement in 2 patients. RESULTS: Mean antegrade cerebral perfusion time was 39 +/- 22 minutes. One patient with acute proximal dissection died because of cerebral complications. One other patient developed right hemiparesis, which resolved during the second postoperative month without sequela. Other than these 2 cases (1.9%), no other neurologic event was observed. CONCLUSIONS: The technique of low flow antegrade selective cerebral perfusion through the right brachial artery may be used for a vast majority of aortic aneurysms and dissections requiring arch repair. This technique does not necessitate deep hypothermia, requires shorter cardiopulmonary bypass and operation times, has the advantage of simplicity, provides optimal vascular repair without time restraints and, in terms of clinical results, is as safe as other techniques for cerebral protection.

Dynamic cardiomyoplasty as a biomechanic bridge to heart transplantation.

We report a heart transplantation that was done 4 years after a dynamic cardiomyoplasty operation. The patient was a 42-year-old man. Radionucleide ventriculography with technetium 99 m revealed an ejection fraction of 18%. In July 1997 he had undergone a dynamic cardiomyoplasty operation. At the first postoperative month the left ventricular ejection fraction was 35%. In September 2000 he presented with heart failure symptoms. In May 2001 he had undergone heart transplantation. Postoperative course was uneventful. The failure of cardiomyoplasty was probably caused by degeneration of the latissimus dorsi muscle. In this case we have learned that muscle viability is lost within 4 years after dynamic cardiomyoplasty and heart transplantation is still an option for those patients.