Comparison of Bretschneider HTK and Blood Cardioplegia (4:1): A Prospective Randomized Study.

BACKGROUND: We compared the effect of intermittent blood and histidine-tryptophan-ketoglutarate (HTK) solution of Bretschneider on myocardial histopathology and perioperative outcome. METHODS: Forty adult cardiac surgery patients were grouped into two (n = 20 for each): (1) Intermittent blood cardioplegia (IBC): had repeated cold 4:1 blood cardioplegia and (2) HTK: had a single dose of cold HTK for cardioprotection. Creatine kinase (CK)-MB, Troponin-I (cTn-I), pH, and lactate were studied in coronary sinus blood before and after aortic cross-clamping (AXC) and systemic blood at postoperative 6th, 24th, and 48th hours. Myocardial biopsy was performed before and after AXC for light microscopy. Vacuolation, inflammation, edema, and glycogen were graded semiquantitatively (from 0 to 3). The myocardial apoptotic index was evaluated via the terminal deoxynucleotidyl transferase dUTP nick end labeling. RESULTS: There were no differences in perioperative clinical outcomes between the groups. The coronary sinus samples after AXC were more acidotic (7.15 ± 0.14 vs. 7.32 ± 0.07, p = 0.001) and revealed higher CK-MB (21.0 ± 12.81 vs. 12.60 ± 11.80, p = 0.008) in HTK compared with IBC. The HTK had significantly a higher amount of erythrocyte suspension intraoperatively compared with IBC (0.21 ± 0.53 vs. 1.68 ± 0.93 U, p = 0.001). Microscopically, myocardial edema was more pronounced in HTK compared with IBC after AXC (2.25 ± 0.91 vs. 1.50 ± 0.04, p = 0.013). While a significant increase in the apoptotic index was seen after AXC in both groups (p = 0.001), no difference was detected between the groups (p = 0.417). CONCLUSION: IBC and HTK have a similar clinical outcome and protective effect, except for more pronounced myocardial edema and increased need for intraoperative transfusion with HTK.

Pulmonary artery sarcoma treated with pulmonary endarterectomy and leaflet reconstruction using Ozaki technique.

Pulmonary arterial intimal sarcomas (PAIS) are rare malignancies with a poor prognosis. Sarcomas present with signs and symptoms mimicking pulmonary thromboembolic disease, delaying the diagnosis. We present a 29-year-old male patient diagnosed with PAIS in the right and main pulmonary arteries extending to the left pulmonary leaflet. The patient was treated with pulmonary endarterectomy and pulmonary leaflet reconstruction using the Ozaki technique.

The preventive and curative effects of melatonin against abdominal aortic aneurysm in rats.

OBJECTIVE: Oxygen free radicals are important components involved in the histopathologic tissue alterations observed during abdominal aortic aneurysms (AAAs). This study examined whether melatonin has protective or therapeutic effects against AAAs. METHODS: Sprague-Dawley rats were divided into four groups. A CaCl2 model was used to induce AAA. Starting on the operation day (Mel+AAA+Mel group) or 4 weeks after the operation (AAA+Mel group), the rats received intraperitoneal melatonin (10 mg/kg/day) for 6 and 2 weeks, respectively. The control and AAA groups received vehicle for 2 weeks after the sham operation and AAA induction, respectively. Angiographic measurements were recorded at the beginning, week 4, and week 6 of the study. After decapitation, aorta tissues were taken for the measurement of malondialdehyde, 8-hydroxy-2'-deoxyguanosine, glutathione levels, and myeloperoxidase and caspase-3 activity. Matrix metalloproteinase (MMP)-2, MMP-9, tumor necrosis factor-α, and inducible nitric oxide synthase protein expressions were analyzed by Western blot technique. Aortic tissues were also examined by light microscopy. RESULTS: CaCl2 caused an inflammatory response and oxidative damage indicated by rises in malondialdehyde and 8-hydroxy-2'-deoxyguanosine levels. Myeloperoxidase and caspase-3 activities were increased, but glutathione levels were reduced. On the one hand, MMP-2, MMP-9, tumor necrosis factor-α, and inducible nitric oxide synthase protein expressions were increased in the vehicle-treated AAA group. On the other hand, melatonin treatment reversed all of these biochemical indices and histopathologic alterations. CONCLUSIONS: According to the data, although melatonin tended to reverse the biochemical parameters given on week 4, the preventive effect is more pronounced when given concomitantly with AAA induction because values were closer to the control levels.

The Perceval Sutureless Valve in Aortic Root Reoperation.

The case is reported of a 62-year-old man with severe aortic regurgitation that was related to failed prior valve-sparing ascending aortic aneurysm repair, and who was successfully treated with a Perceval Sutureless valve.

Correction of cortriatriatum sinister with classical Raghib's complex using an extracardiac conduit.

We present a 32-year-old patient with cortriatriatum sinister with Raghib's complex (a left persistent superior vena cava draining into the left atrium with an absent coronary sinus and an atrial septal defect [ASD]) who underwent successful surgical correction with excision of the cortriatriatum, closure of the ASD, and establishing the drainage of the persistent left superior vena cava to the right atrium via interposition of an extracardiac 13-mm ringed polytetrafluoroethylene conduit.

Direct transapical implantation of an endocardial pacing lead to the left ventricle: an alternate pacing site after tricuspid valve replacement.

In this paper, we report an alternative approach for implantation of ventricular pacing lead for complete atrioventricular block after tricuspid valve replacement.

Effect of body mass index on early morbidity and mortality after isolated coronary artery bypass graft surgery.

OBJECTIVES: Obesity is a risk factor for morbidity after isolated coronary artery bypass grafting. This study aimed to analyze the sole effect of body mass index (BMI) on early morbidity and mortality in patients after isolated coronary artery bypass grafting. DESIGN: This study was retrospective and used an electronic database of anesthesia information management. SETTING: A single community hospital. PARTICIPANTS: The data of 803 consecutive patients after isolated on-pump coronary artery bypass grafting were analyzed retrospectively; off-pump cases were excluded. INTERVENTION: According to measured BMI, patients were divided into 5 groups: underweight (BMI <20 kg/m(2)), normal weight (BMI 20.0-24.9 kg/m(2)), overweight (BMI 25.0-29.9 kg/m(2)), obese (BMI 30.0-34.9 kg/m(2)), and morbidly obese (BMI >34.9 kg/m(2)). Early postoperative morbidity and mortality were evaluated using logistic regression analysis. MEASUREMENTS AND MAIN RESULTS: Early cumulative postoperative mortality was 3.9% (32 of 803 patients). Mortality was recorded in 3 underweight (n = 15, 20%, odds ratio [OR] 6.54, p = 0.001), 9 normal-weight (n = 159, 5.7%, OR 1.62, p = 0.228), 12 overweight (n = 371, 3.2%, OR 0.68, p = 0.314), 6 obese (n = 199, 3.0%, OR 0.69, p = 0.421), and 2 morbidly obese (n = 59, 3.4%, OR 0.83, p = 0.808) patients. Prolonged intensive care unit stay (p < 0.001), prolonged hospital stay (p < 0.001), and mortality (p = 0.01) were significantly more common in patients in the underweight group than in the other groups. Univariate and multivariate logistic regression analyses showed that underweight, hypertension, and chronic renal failure were independent risk factors for mortality. CONCLUSIONS: Underweight patients with a BMI <20 kg/m(2) are at increased risk of postoperative complications and mortality compared with normal-weight or overweight subjects.

Mid-term results of surgical interventions of high-grade vena cava tumor thrombus.

Background: This study aims to investigate whether the coexistence of advanced renal cell carcinoma and inferior vena cava tumor thrombus could be treated with a multidisciplinary approach and teamwork and to evaluate early and mid-term results. Methods: Between January 2017 and December 2020, a total of 33 patients (28 males, 5 females; mean age: 55.8±13.2 years; range, 27 to 76 years) who underwent radical nephrectomy and thrombectomy of the inferior vena cava were retrospectively analyzed. Demographic characteristics of the patients, types of operations, postoperative data, mortality and morbidity rates were recorded. Results: Of the patients, 12% (n=4) had Stage 2 tumor thrombus, 60.6% (n=20) had Stage 3 tumor thrombus, and 27% (n=9) had Stage 4 tumor thrombus. A total of 55% (n=19) of the patients had right-sided renal cell carcinoma, while 45% (n=14) of them had a left-sided mass. Totally, 66% (n=22) of the patients underwent primary inferior vena cava repair. The thrombectomy procedure and a Dacron® patch was applied with patch plasty in 24% (n=8) of the patients, and Dacron® graft interposition was applied to the inferior vena cava in 9% (n=3) of the patients. The mean follow-up was 20.3±13.0 (range, 2 to 70) months. Deep vein thrombosis was detected in the follow-up of seven (21%) patients, and no pulmonary thromboembolism was observed during the postoperative follow-up period. The mean length of stay in the intensive care unit was 1.39±0.6 (range, 1 to 3) days. The 30-day mortality rate was 3%, due to the loss of one patient from massive pulmonary embolism intraoperatively. Conclusion: Vascular surgical procedures performed regardless of the stage of the tumor thrombus provide satisfactory mid-term results in patients with advanced renal cell cancer.

Surgical treatment of massive pulmonary thromboembolism due to renal cell carcinoma.

While renal cell carcinomas frequently invade the renal vein and inferior vena cava, the right atrial extension or formation of bilateral pulmonary massive embolism is quite unusual. A 65-year-old male patient underwent bilateral pulmonary tumor endarterectomy and total thrombectomy of the inferior vena cava combined with left nephrectomy under total circulatory arrest with antegrade cerebral perfusion. Both mediastinal and abdominal approaches facilitated the complete removal of the caval thrombus under the guidance of transesophageal echocardiography. The patient is still under follow-up for six months without metastasis. In conclusion, pulmonary thromboembolism due to renal cell carcinoma is rare, surgical treatment is possible.

Autologous right pulmonary artery tissue for repair of left pulmonary artery originating from left patent ductus arteriosus in a patient with tetralogy of Fallot and absent pulmonary valve.

Left pulmonary artery (PA) originating from patent ductus arteriosus is an exceptionally rare variant of tetralogy of Fallot with absent pulmonary valve. We described an alternative technique for the repair of discontinuous left PA with the use of the redundant pulmonary artery tissue as material for the conduit in a 3-year-old boy.

Testicular germ cell tumor metastatic to the right atrium.

We describe a right atrial metastasis of a testicular germ cell tumor, which was successfully removed from the tricuspid valve and subvalvular apparatus without the need for valve replacement.

Subclavian flap aortoplasty for infant coarctation of the aorta

Aortic resection with an extended end-to-end anastomosis is the surgical gold standard treatment for infant aortic coarctation and has excellent early and long-term outcomes.  Subclavian flap aortoplasty is an alternative surgical technique that offers some advantages because there is no need to do extensive dissection and mobilization of the aortic arch and descending aorta as required in an extended end-to-end anastomosis.  This video tutorial illustrates the technical aspects of subclavian flap aortoplasty in an infant.

Histopathologic evaluation of saphenous vein grafts in patients with type II diabetes mellitus undergoing coronary artery bypass grafting.

INTRODUCTION: Diabetes Mellitus (DM) has been known to be a risk factor for the development of more severe form of saphenous vein graft disease after coronary artery bypass grafting (CABG). We aimed to evaluate the impact of type II-DM on histopathological features of great saphenous vein grafts of patients undergoing CABG. PATIENTS AND METHODS: Forty consecutive patients undergoing elective CABG were enrolled into the study. Patients were grouped into two; Diabetic group (n = 20); includes patients with preoperative diagnosis of type II-DM and Nondiabetic group (n = 20): those without type II-DM. In all patients, a short segment of the great saphenous vein graft at the level of medial malleolus was taken for light microscopy and transmission electron microscopy (TEM) evaluation. Moreover, immunoexpressions of Caveolin-1, Vascular cell adhesion protein 1 (VCAM-1) and endothelial nitric oxide synthase (eNOS) were studied. RESULTS: There were no differences in the demographics of patients between two groups. The magnitude of intimal fibrosis in diabetic group was slightly higher than in nondiabetics (1.95 ± 0.99 versus 1.3 ± 0.8, P = .04). In TEM, vacuolization in endothelial cells, substance accumulation along with coarse collagen fibers and cytoplasmic degeneration with vacuolization in muscle cells were detected in diabetic group. While there were no differences in Caveolin-1 and VCAM-1 immunostaining, the intensity of positive eNOS immunostaining was significantly higher in endothelium (2.10 ± 0.64 versus 1.55 ± 0.68, P = .01) and tunica media 1.75 ± 0.63 versus 1.2 ± 0.52, P = .007) in nondiabetic group, respectively) compared with diabetic group. CONCLUSION: Type II DM might be a reason for decreased expression of eNOS and increased intimal fibrosis, vacuolization of endothelial and smooth muscle cells in saphenous vein grafts. The clinical implications of these alterations on the graft patency need to be evaluated.

A simple maneuver on sternal saw facilitates to perform curved sternal mini-incisions like J- and C-shaped partial sternotomies.

Minimal invasive approaches, including partial J- or C-shaped sternotomies, have gained a worldwide acceptance in cardiac surgical practice. To increase the cosmetic benefit and improve the surgical exposure, the length of underlying partial sternotomy is usually 3 to 5 cm longer than the length of skin incision in most of these approaches. Using a standard sternal saw or a rotary craniotome, it is quite difficult to make sternal incision under subcutaneous tissue at both ends of skin incision. Moreover, standard sternal saws do not allow doing fine manipulations on sternum that may cause inadvertent sternal cutting, especially at the curved parts of C- or J-type partial sternotomies. We removed the blade protector part of a standard sternal saw. This simple maneuver enables surgeons to perform several challenging mini-sternotomies easily for adult cardiac procedures.

Thromboelastography-based transfusion algorithm reduces blood product use after elective CABG: a prospective randomized study.

OBJECTIVE: Bleeding and allogeneic transfusion remain constant problems in cardiac surgical procedures. In this study, we aimed to test the role of a routine thromboelastography (TEG)-based algorithm on bleeding and transfusions in patients undergoing elective coronary artery bypass grafting (CABG). METHODS: Patients (n = 224) undergoing elective CABG with cardiopulmonary bypass were prospectively randomized into two groups according to transfusion strategy: in group 1 (clinician-directed transfusion, n = 110) need for blood transfusion was based on clinician's discretion and standard coagulation tests and in group 2 (TEG algorithm group, n = 114) kaolin-activated (k) TEG-based algorithm-guided perioperative transfusion management. Transfusion, blood loss, and outcome data were recorded. RESULTS: There were no differences in consumption of packed cell units, blood loss, re-exploration for bleeding, and early clinical outcome between the groups. Patients in the TEG group had significantly lower median units of fresh frozen plasma and platelets compared with the other group (p = 0.001). The median number of total allogeneic units transfused (packed cells and blood products) was significantly reduced in the TEG group compared with the other group (median 2, range 1-3 units vs. median 3, range 2-4 units, respectively, p = 0.001). The need for tranexamic acid was significantly diminished in the TEG group compared with the other group (10.3% vs. 19%, respectively, p = 0.007). CONCLUSION: Our results show that routine use of a kTEG-guided algorithm reduces the consumption of blood products in patients undergoing elective CABG. Adopting such an algorithm into routine management of these patients may help to improve clinical outcome and reduce the potential risks of transfusion-related complications and total costs after CABG.

[The effect of transmyocardial laser revascularization on anginal symptoms and clinical results in patients with incomplete surgical revascularization]. / Tam cerrahi revaskülarizasyon yapilamayan hastalarda transmiyokardiyal lazer revaskülarizasyonu isleminin anjinal semptomlar ve klinik sonuçlar üzerine etkisi.

OBJECTIVES: We evaluated the effect of transmyocardial laser revascularization (TMR) on anginal symptoms and clinical results in patients in whom coronary artery bypass grafting (CABG) surgery was not sufficient to provide complete revascularization. STUDY DESIGN: This retrospective study included 45 patients who underwent CABG surgery with incomplete revascularization between 2003 and 2006. Of these, 35 patients (mean age 61.7 years) had CABG alone, while 10 patients (mean age 62 years) underwent TMR at the same session as an adjunct to CABG. All the patients were assessed by transthoracic echocardiography and myocardial perfusion scintigraphy at three months and after a mean follow-up period of 22.3+/-6.1 months. Anginal symptoms were assessed using the CCS (Canadian Cardiovascular Society) classification system. RESULTS: Preoperative variables were similar in both groups. All the patients were symptomatic preoperatively with mean CCS scores of 2.6+/-0.5 and 2.3+/-0.8 in the TMR and CABG-alone groups, respectively. The duration of cardiopulmonary bypass (CPB) was significantly longer in the TMR group (p=0.022). During weaning from CPB, the need for inotropic support was significantly less in the TMR group (10% vs. 48.6%; p=0.034). While there was no early mortality, late mortality occurred in three patients (1 in TMR, 2 in CABG-alone groups; p=0.329). At three months, 50% (n=5) of the TMR patients were asymptomatic, compared to 14.3% (n=5) in the CABG-alone group (p=0.016). Patients in the TMR group had significantly lower CCS angina scores at three months (1.2+/-0.6 vs. 2.2+/-0.7; p=0.001) and at the end of the follow-up (1+/-0.6 vs. 2+/-0.7; p=0.001). There were no significant differences between the two groups with regard to the findings of myocardial perfusion scintigraphy and echocardiography. CONCLUSION: Patients with incomplete surgical revascularization benefit from TMR in terms of decreased need for inotropic support during weaning from CPB and short- and mid-term relief of angina symptoms.

Repair of Scimitar syndrome using an extracardiac conduit in pediatric patients: Report of two patients.

Scimitar syndrome (SS) can be repaired by different surgical techniques including direct implantation, intracardiac rerouting, and in situ pericardial channel to direct the Scimitar vein (SV) to the left atrium. The presence of several anatomical variations such as remote infradiaphragmatic drainage of the SV and abnormal situs makes the repair more challenging with conventional repair techniques. In this paper, we present our experience in using an extracardiac-ringed polytetrafluoroethylene conduit in two pediatric patients (14 months and 2 years old) with SS.

The effect of NQO1 polymorphism on the inflammatory response in cardiopulmonary bypass.

Cardiopulmonary bypass (CPB) has been associated with systemic inflammatory response syndrome (SIRS). Endothelial dysfunction related to non-laminar flow during CPB is known to play a key role in this complex pathology. Antioxidant response element (ARE) dependent NAD(P)H:quinone oxidoreductase 1 (NQO1) promoter is a regulatory element involved in the anti-inflammatory mechanism in vasculature exposed to non-laminar flow. Mutation of the NQO1 could represent a novel anti-inflammatory effect in CPB. The goal of this study was to demonstrate whether genetic variants of NQO1 affect cytokine release after CPB. Eighteen patients who underwent standard coronary artery bypass grafting (CABG) operation were included in the study. Genotyping for NQO1 was performed. Serum Interleukin-6 (IL-6) levels were measured before induction, during CPB after declamping the aorta, and 24 h after operation. Clinical data were collected respectively. Seven patients were NQO1 T carriers and 11 patients were NQO1 T non-carriers. During CPB, IL-6 concentrations were increased in NQO1 T carriers compared to T non-carriers (p = 0.038). Although ventilation times and blood loss were higher in T carriers these were not statistically significant. Patients with NQO1 T carriers showed significantly higher IL-6 levels during CPB. Non-laminar flow during CPB may diminish the transcriptional activation of the NQO1 in T carriers. Preoperative determination of this novel anti-inflammatory mechanism could be useful to improve operative outcome in CPB.

Effect of Ala16Val genetic polymorphism of MnSOD on antioxidant capacity and inflammatory response in open heart surgery.

BACKGROUND: Ischemia-reperfusion injury and inflammation in cardiac surgical patients involves complex humoral and cellular interactions. We investigated the effect of genetic polymorphism of manganase superoxide dismutase (MnSOD) a natural antioxidant, on cytokine release and manganesuperoxide dismutase in patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB). PATIENTS AND METHODS: Forty-two patients undergoing elective CABG with CPB were included in the study. MnSOD polymorphism was performed by polymerase chain reaction (PCR). Levels of interleukin-6 and mangane superoxide dismutase (MnSOD) were measured by enzyme linked immunoabsorbent assay (ELISA). RESULTS: Baseline IL-6 did not differ between patients with different MnSOD genotypes. Postoperatively IL-6 levels were significantly higher in all patients but more significantly in V(VV+AV) carriers (p=0.003). The wild-type AA genotype had the highest preoperative (p<0.05) and postoperative IL-6 level. The MnSOD VV genotype was associated with significantly lower preoperative MnSOD levels compared to the AA carriers (p<0.05). CONCLUSION: These data demonstrate that MnSOD Ala16Val polymorphism influences IL-6 production and baseline MnSOD activity, suggesting that preoperative MnSOD concentration plays a role in cytokine release.