Myocardial Protection in Isolated Coronary Artery Bypass Grafting: Del Nido versus Blood Cardioplegia.

INTRODUCTION: Our study aimed to examine the impacts of blood cardioplegia (BC) and del Nido cardioplegia (DNC) solutions - which we used in isolated coronary artery bypass grafting (CABG) - on early mortality and major adverse events (MAE). METHODS: We retrospectively analyzed 329 consecutive patients who underwent CABG in our clinic between January 2016 and January 2020. Myocardial infarction, reoperation, cardiac tamponade, stroke, renal failure, extracorporeal membrane oxygenation requirement, and cardiopulmonary resuscitation were defined as MAE. The group in which DNC was used was Group D (181 [55%] patients), and the group in which BC was used was Group B (141 [45%] patients). RESULTS: No statistically significant difference was determined between the groups regarding age, weight, body surface area, gender, or European System for Cardiac Operative Risk Evaluation score (P=0.615, P=0.560, P=0.934, P=0.365, P=0.955, respectively). Although there was no statistically significant difference between the groups in terms of aortic cross-clamping time (P=0.712), cardiopulmonary bypass duration was longer in Group B (P=0.001). Even though the incidence of stroke was higher in Group B (P=0.030), no statistically significant difference was observed between the groups regarding total incidence of MAE, mortality, mechanical ventilation time, length of stay in the intensive care unit, or length of hospital stay (P=0.153, P=0.130, P=0.689, P=0.710, P=0.613, respectively). CONCLUSION: We found no significant difference in MAE, mortality, duration of mechanical ventilation, intensive care unit stay, or hospital stay between the DNC and BC groups. We believe that both solutions can be used safely for cardiac protection in the adult patient population.

The role of alpha-1-antitrypsin in the etiopathogenesis of chronic venous disease: A prospective clinical trial.

OBJECTIVE: The study aimed to examine whether alpha-1-antitrypsin (AAT), an inhibitor of leukocyte esterase(LE), which damages the venous vessel wall, has a protective effect against chronic venous disease(CVD), and to examine the relationship between AAT levels and disease severity. METHODS: Patients admitted with varicose vein disease and having reflux flow lasting longer than 0.5 s as determined by Doppler ultrasound were included. The informed consents were taken, and blood samples were obtained for complete blood count, C-reactive protein (CRP) level, and AAT level following anamnesis and physical examination. Clinical Etiologic Anatomic Pathologic (CEAP) classification was used to assess disease severity, and patients were divided into CEAP 1-5 groups accordingly. RESULTS: A total of 87 patients were included in the study. There was no statistically significant difference between the groups in body weight, red blood cell counts, platelet counts, or neutrophil counts (p = 0.117, p = 0.932, p = 0.177, and p = 0.177, respectively).CRP and AAT levels were higher in patients with a CEAP clinical score of 5 compared to the other groups (p = 0.018, and p = 0.020, respectively). AAT levels were similar in the CEAP 1-3 group and decreased in the CEAP-4 group but increased again in the CEAP-5 group. The AAT level was 1.62 ± 0.3 g/L in the CEAP-1 group, 1.61 ± 0.21 g/L in the CEAP-2 group, 1.61 ± 0.27 g/L in the CEAP-3 group, 1.48 ± 0.28 g/L in the CEAP-4 group, and 1.94 ± 0.39 g/L in the CEAP-5 group. CRP levels and platelet counts were observed to affect AAT levels (p = 0.10, p = 0.017, respectively). CONCLUSION: We believe that our hypothesis that low AAT levels play a role in the etiopathogenesis of CVD has been partially validated, at least in the CEAP-4 group. However, we believe that increased AAT levels in the CEAP-5 group may be a reactive increase in increased LE levels due to higher CRP levels of this group.

Clinical evaluation of two adult oxygenator systems in terms of mortality and major adverse events.

PURPOSE: The primary aim of this study was to examine the effects of two oxygenator systems on major adverse events and mortality. METHODS: A total of 181 consecutive patients undergoing coronary artery bypass grafting in our clinic were retrospectively analyzed. The patients were divided into two groups according to the oxygenator used: Group M, in which a Medtronic Affinity (Medtronic Operational Headquarters, Minneapolis, MN, USA) oxygenator was used, and Group S, in which a Sorin Inspire (Sorin Group Italia, Mirandola, Italy) oxygenator was used. RESULTS: Group S consisted of 89 patients, whereas Group M included 92 patients. No statistically significant differences were found between the two groups in terms of age (p = .112), weight (p = .465), body surface area (p = .956), or gender (p = .484). There was no statistically significant difference in hemorrhage on the first or second postoperative day (p = .318 and p = .455, respectively). No statistically significant differences were observed in terms of red blood cell (p = .468), fresh frozen plasma (p = .116), or platelet concentrate transfusion (p = .212). Infections, wound complications, and delayed sternal closure were significantly more common in Group M (p = .006, p = .023, and p = .019, respectively). Extracorporeal membrane oxygenators and intra-aortic balloon pumps were required significantly more frequently in Group S (p = .025 and p = .013, respectively). Major adverse events occurred in 16 (18%) patients in Group S and 14 (15.2%) patients in Group M (p = .382). Mortality was observed in six (6.7%) patients in Group S and three (3.3%) patients in Group M (p = .232). No statistically significant difference was found between the two groups in terms of length of hospital stay (p = .451). CONCLUSION: The clinical outcomes of the two oxygenator systems, including mortality, major adverse events, hemorrhage, erythrocyte and platelet transfusions, and length of hospital stay, were similar.

Myocardial Protection in Isolated Coronary Artery Bypass Grafting: Del Nido versus Blood Cardioplegia

ABSTRACT Introduction: Our study aimed to examine the impacts of blood cardioplegia (BC) and del Nido cardioplegia (DNC) solutions - which we used in isolated coronary artery bypass grafting (CABG) - on early mortality and major adverse events (MAE). Methods: We retrospectively analyzed 329 consecutive patients who underwent CABG in our clinic between January 2016 and January 2020. Myocardial infarction, reoperation, cardiac tamponade, stroke, renal failure, extracorporeal membrane oxygenation requirement, and cardiopulmonary resuscitation were defined as MAE. The group in which DNC was used was Group D (181 [55%] patients), and the group in which BC was used was Group B (141 [45%] patients). Results: No statistically significant difference was determined between the groups regarding age, weight, body surface area, gender, or European System for Cardiac Operative Risk Evaluation score (P=0.615, P=0.560, P=0.934, P=0.365, P=0.955, respectively). Although there was no statistically significant difference between the groups in terms of aortic cross-clamping time (P=0.712), cardiopulmonary bypass duration was longer in Group B (P=0.001). Even though the incidence of stroke was higher in Group B (P=0.030), no statistically significant difference was observed between the groups regarding total incidence of MAE, mortality, mechanical ventilation time, length of stay in the intensive care unit, or length of hospital stay (P=0.153, P=0.130, P=0.689, P=0.710, P=0.613, respectively). Conclusion: We found no significant difference in MAE, mortality, duration of mechanical ventilation, intensive care unit stay, or hospital stay between the DNC and BC groups. We believe that both solutions can be used safely for cardiac protection in the adult patient population.

More Successful Results with Less Energy in Endovenous Laser Ablation Treatment: Long-term Comparison of Bare-tip Fiber 980 nm Laser and Radial-tip Fiber 1470 nm Laser Application.

BACKGROUND: Varices and venous insufficiency are common and serious health problems in the general population which affect the quality of life. Endothermal treatment of the great saphenous vein has become the first line of treatment for superficial venous reflux, and the endovenous laser ablation (EVLA) method has been widely accepted all over the world. In this method, ablation is provided by a laser fiber inserted into the lumen of the vein. Initially, the fibers were 810 nm, but today the fibers are usually 940, 980, or 1470 nm. METHODS: The study included 400 patients (419 procedures) who were diagnosed with venous insufficiency and underwent 980 and 1470 nm EVLA. Patients were followed up for 48 months. A 980-nm bare-tip laser catheter in Group A and a 1470-nm radial-tip laser catheter in Group B were inserted until they were 2 cm below the saphenofemoral junction. An EVLA catheter was drawn slowly at the rate of 1-3 cm/sec (2.08 ± 0.6). The energy applied to the saphenous vein was 60-120 J/cm (84.65 ± 13.03) and 45-120 J/cm (76.95 ± 15.06) in Group A and Group B, respectively (P < 0.001), with 15 W in the continuous mode. Follow-up visits included a physical examination and Doppler ultrasonography performed at the following time points: day 1, week 1, and months 1, 6, 12, 24, 36, and 48. Saphenous vein occlusion rates and postprocedure saphenous vein diameters were evaluated at each follow-up visit. Pain levels were evaluated using the Wong-Baker FACES® pain scale (0-10). Postoperative complications were recorded. RESULTS: Group A (980 nm laser) consisted of 200 patients with a mean age of 37.84 ± 12.2 years. Group B (1470 nm laser) consisted of 200 patients with a mean age of 38.38 ± 12.1 years. The mean duration of the procedure was 32.2 ± 9.7 min in Group A and 31.7 ± 8.8 min in Group B, respectively (P = 0.47). Induration, ecchymosis, and paresthesia rates were significantly higher in the bare-tip laser group. The most important complication, deep vein thrombosis, was observed in 4 patients in Group A. Recanalization rates were found to be increased by prolonged follow-up periods. At the 48-month follow-up, this rate was 15.9% in Group A and 8.3% in Group B (P = 0.017). This rate showed that the 1470-nm wavelength laser treatment was more successful in Group B than in Group A over the long term. CONCLUSIONS: Both the 980 and 1470 nm wavelength laser-assisted EVLA procedures appear to be effective in treating saphenous vein insufficiency. The 1470-nm radial-tip fiber is preferred due to lower energy levels, lower complication rates, early return to daily life, and the successful long-term occlusion rate.

N-butyl cyanoacrylate in the treatment of venous insufficiency--the effect of embolisation with ablative polymerisation.

BACKGROUND: The primary objective of this multicentre prospective observational study was to evaluate the early results of a new non-thermal embolisation method using N-butyl cyanoacrylate in venous insufficiency. PATIENTS AND METHODS: A total of 181 patients with a varicose vein diagnosis were treated with the VariClose: Vein Sealing Systems at four different centres. The protocol included physical and colour Doppler ultrasonography examination, venous clinical severity score and quality of life assessment before and after the procedure on days 1 and 7 and at months 1, 3 and 6. Clinical recovery was evaluated by comparing the venous clinical severity score and the quality of life assessment before and after the procedure. RESULTS: In total, 215 embolisation procedures were successfully completed on 181 patients (110 female) with a mean age of 37.6 ± 13.2 years (range 18-72 years). The 215 procedures consisted of 25 bilateral applications on 206 great saphenous veins and 9 small saphenous veins. The average pre-interventional diameter of great saphenous veins was 6.5 ± 1.4 mm (4.3-14 mm), and the mean diameter of small saphenous veins was 5.2 ± 1.3 mm (3.8-8.6 mm). The average length of the sealed vein segments was 31.6 ± 6.1 cm (23-70 cm), and the average N-butyl cyanoacrylate usage for the patient was 0.9 ml (0.7-2.1 ml). The procedural occlusion rate was 100%. Post-operative pain was observed in 11 patients (6.1%), and thrombophlebitis was observed in 1 patient (0.5%). No total recanalisation was observed. Five (2.7%) partial recanalisations were observed at the 6 month follow-up. The 6 month total occlusion rate was 97.2%. CONCLUSIONS: This new tumescent-free non-thermal embolisation method can be applied safely with high success rates.

Evaluation of patency following revision technique of high-velocity arteriovenous fistula.

BACKGROUND/AIM: The objective of this study is to report our experience with surgical revision of dialysis access-induced ischemia syndrome. MATERIALS AND METHODS: Between January 2005 and July 2013, 1254 patients underwent arteriovenous fistula operation, and 86 of them [53 males, mean age: 55 ± 25 (range: 25 to 75) years; 33 females, mean age: 50 ± 20 (range: 30 to 70) years] subsequently developed steal syndrome. These patients were treated with arterial pressure-controlled polytetrafluoroethylene banding or constriction with polypropylene suturing technique. Patients were followed in the outpatient clinic at regular intervals. RESULTS: Symptoms were not relieved during the first 15 days in 4 patients; therefore, reintervention was performed. Thrombosis occurred in one patient after reintervention. No early or late complications were detected in other patients, and fistulae were suitable for hemodialysis. Patency rates at 6 and 12 months were 96% and 92%, respectively, and thrombosis rates were 7% and 9%. There was no hospital mortality in our study, but one patient died from unrelated causes and two other patients quit follow-up after 6 months. CONCLUSION: We think that arterial pressure-controlled surgical revision is an effective and safe technique in patients with fistula-related hand ischemia.

Acute Mitral Valve Dysfunction Due to Escape of Prosthetic Mechanical Leaflet and Peripheral Leaftlet Embolization.

BACKGROUND: Leaflet escape of prosthetic valve is rare but potentially life threatening. Early diagnosis is essential on account of avoiding mortality, and emergency surgical correction is compulsory. This complication has previously been reported for both monoleaflet and bileaflet valve models. METHODS: A 30-year-old man who had undergone mitral valve replacement with a bileaflet valve 8 years prior at another center was admitted with acute-onset with cardiogenic shock as an emergency case. Transthoracic echocardiograms showed acute-starting severe mitral regurgitation associated with prosthetic mitral valve. There was a suspicious finding of a single prosthetic mitral leaflet. But the problem related with the valve wasn't specifically determined. The patient underwent emergent surgery for replacement of the damaged prosthetic valves immediately. There was no tissue impingement and thrombosis, one of the two leaflets was absent, and there were no signs of endocarditis or pannus formation in the prosthetic valve. The missing leaflet could not be found within the cardiac cavity. The abdominal fluoroscopic study and plain radiography were unable to detect the escaped leaflet during surgery. The damaged valve was removed and a replacement 29 mm bileaflet mechanical valve was inserted by right lateral thoracotomy. RESULTS: After post-operative week one, the abdominal computed tomography scan and the ultrasound showed the escaped leaflet in the left femoral artery. Fifteen days after the surgery the escaped leaflet was removed safely from the left femoral artery and the patient made a complete recovery. CONCLUSION: The escaped leaflet showed a fracture of one of the pivot systems caused by structural failure. Early cardiac surgery should be applied because of life-threatening problems.

Chronic dissecting aneurysm of the ascending aorta developed in a patient who had rejected surgical treatment for type II acute ascending aortic dissection three years earlier.

A 66-year-old male patient was admitted to our clinic because of shortness of breath and chest pain. A grade 4/6 diastolic murmur was heard on auscultation. Physical examination revealed signs of congestive heart failure and poor peripheral perfusion. There was a diagnosis of type II ascending aortic dissection in the history of the patient. He had refused emergency surgical intervention three years earlier. Computed tomography revealed that the ascending aorta was dilated to about 10 cm in diameter, and there was a chronic aortic type II dissection. The patient had second- to third-degree aortic insufficiency and he had a calcified bicuspid aortic valve on echocardiography. Two-vessel disease and a 90-mmHg aortic gradient were detected on angiography. Graft replacement of the ascending aorta, serape aortic valve replacement with a mechanical valve, and coronary arterial bypass grafting were performed successfully under cardiopulmonary bypass with an open aortic technique. The patient was discharged on the 10th postoperative day with no problems.

On-pump beating-heart versus conventional coronary artery bypass grafting for revascularization in patients with severe left ventricular dysfunction: early outcomes.

BACKGROUND: We sought to evaluate the effects of on-pump beating-heart versus conventional coronary artery bypass grafting techniques requiring cardioplegic arrest in patients with coronary artery disease with left ventricular dysfunction. METHODS: We report the early outcomes associated with survival, morbidity and improvement of left ventricular function in patients with low ejection fraction who underwent coronary artery bypass grafting between August 2009 and June 2012. Patients were separated into 2 groups: group I underwent conventional coronary artery bypass grafting and group II underwent an on-pump beating-heart technique without cardioplegic arrest. RESULTS: In all, 131 patients underwent coronary artery bypass grafting: 66 in group I and 65 in group II. Left ventricular ejection fraction was 26.6% ± 3.5% in group I and 27.7% ± 4.7% in group II. Left ventricular end diastolic diameter was 65.6 ± 3.6 mm in group I and 64.1 ± 3.2 mm in group II. There was a significant reduction in mortality in the conventional and on-pump beating-heart groups (p < 0.001). Perioperative myocardial infarction and low cardiac output syndrome were higher in group I than group II (both p < 0.05). Improvement of left ventricular function after the surgical procedure was better in group II than group I. CONCLUSION: The on-pump beating-heart technique is the preferred method for myocardial revascularization in patients with left ventricular dysfunction. This technique may be an acceptable alternative to the conventional technique owing to lower postoperative mortality and morbidity.

CONTEXTE: Nous avons voulu comparer les effets du pontage coronarien sur coeur battant sous CEC (circulation extracorporelle) et ceux du pontage coronarien classique exigeant un arrêt cardioplégique chez des patients atteints de coronaropathie et de dysfonction ventriculaire gauche. MÉTHODES: Nous faisons état des premiers résultats aux plans de la survie, de la morbidité et de l'amélioration de la fonction ventriculaire gauche chez des patients qui avaient une fraction d'éjection faible et qui ont reçu un pontage coronarien entre août 2009 et juin 2012. Les patients ont été répartis en 2 groupes : le groupe I a été soumis à la technique de pontage coronarien classique et le groupe II a été soumis à la technique à coeur battant sous CEC sans arrêt cardioplégique. RÉSULTATS: En tout, 131 patients ont reçu un pontage coronarien : 66 dans le groupe I et 65 dans le groupe II. La fraction d'éjection ventriculaire gauche était de 26,6 % ± 3,5 % dans le groupe I et de 27,7 % ± 4,7 % dans le groupe II. Le diamètre télédiastolique ventriculaire gauche était de 65,6 ± 3,6 mm dans le groupe I et de 64,1 ± 3,2 mm dans le groupe II. On a noté une réduction significative de la mortalité dans les groupes soumis à l'intervention classique et à l'intervention à coeur battant sous CEC (p < 0,001). L'infarctus du myocarde peropératoire et le syndrome de faible débit cardiaque ont été plus fréquents dans le groupe I que dans le groupe II (tous deux p < 0,05). L'amélioration de la fonction ventriculaire gauche après l'intervention chirurgicale a été plus marquée dans le groupe II que dans le groupe I. CONCLUSION: La technique à coeur battant sous CEC est la méthode préférée de revascularisation myocardique chez les patients atteints d'une dysfonction ventriculaire gauche. Cette technique peut être une solution de rechange acceptable à la technique classique en raison des taux de mortalité et de morbidité postopératoires plus faibles qui y sont associés.

The relationship between arteriovenous fistula success and inflammation.

BACKGROUND: Arteriovenous fistula (AVF) is the most important vascular access method for hemodialysis (HD). In this study, the relationship between AVF success and inflammation in patients who had HD due to end-stage renal failure (ESRF) was investigated. MATERIAL AND METHOD: In the study, a total of 658 patients, who started HD for ESRF, were evaluated retrospectively. A total of 386 patients were included in this study. The demographic data and C-reactive protein, albumin and fibrinogen levels were investigated in patients with recognized success AVF. RESULTS: In total 311 patients with successful AVF and 75 unsuccessful AVFs were found. In unsuccessful AVF group the average low albumin level, high C-reactive protein and fibrinogen levels were found to be statistically meaningful when compared with successful AVF group (p < 0.001, p < 0.001, p < 0.001). CONCLUSION: As a result, we think that the evaluation of inflammation before creating AVF in HD patients is very important for increasing the success of AVF.

Is administration of preoperative angiotensin-converting enzyme inhibitors important for renal protection after cardiac surgery?

OBJECTIVE: There are various reasons for renal dysfunction after cardiac surgery; however, activation of the renin-angiotensin system has an important role following cardiac surgery. We investigated the effect of preoperative angiotensin-converting enzyme (ACE) inhibitors on renal functions after cardiovascular surgery. MATERIAL-METHODS: Three hundred sixty-six patients awaiting elective cardiac surgery were allocated to two groups, namely the treatment group, comprising the ACE inhibitor group (n = 186), and the control group, which was without ACE inhibitor (n = 180). The renal parameters [blood urea nitrogen, creatinine, creatinine clearance, and glomerular filtration rate (GFR)] and the need for dialysis were evaluated associated with renal functions between the two groups in the postoperative period. RESULTS: After cardiac surgery, renal dysfunction requiring dialysis developed in 11 (3.8%) patients in the control group patients. There was no required dialysis in the treatment group (p < 0.05). As an indicator of renal dysfunction, the increase in creatinine and blood urea nitrogen levels and the decrease in GFR and creatinine clearance were higher in the control group (p < 0.05). The multivariate analysis indicated that therapy with ACE inhibitors was found to decrease the incidence of postoperative renal dysfunction (odds ratio, 1.07; 95% confidence interval, 0.45-2.50; p < 0.05). The other independent predictors were age, preoperative intra-aortic blood pump, hypertension, diabetes mellitus, and a left ventricular ejection fraction below 0.40. CONCLUSION: Preoperative therapy with ACE inhibitors has an influence on renal functions. This study demonstrates that administration of ACE inhibitors provides better renal protection after cardiac surgery.

Posterior pericardiotomy reduces the incidence of atrial fibrillation, pericardial effusion, and length of stay in hospital after coronary artery bypasses surgery.

Artrial fibrillation is the most common arrhythmia that occurs after coronary bypass grafting operation with the rate of 30%. Atrial fibrillation is associated with hemodynamic instability, strokes, and prolonged hospital stay. Pericardial effusion is a risk factor for atrial fibrillation after cardiac surgery, and it occurs commonly in the posterior area during the post-operative period. The aim of this prospective study was to demonstrate the effectiveness of posterior pericardiotomy in reducing the incidence of atrial fibrillation. This prospective randomized study was carried out on 425 patients undergoing a coronary artery bypass grafting in our clinic between August 2009 and February 2011. There were 276 male patients and 149 female patients. These patients were randomly divided into two groups; posterior pericardial incision was performed in 213 patients (pericardiotomy group), while any pericardial incision was not performed in 212 patients (control group). Atrial fibrillation occurred more frequently in control group (62 patients, 14.6%), compared to the pericardiotomy group (14 patients, 3.1%; p < 0.0001). The incidences of early pericardial effusion, late pericardial effusion, and tamponade were also significantly higher in control group. Moreover, posterior pericardiotomy was associated with the decreases in the duration of stay in hospital and intensive care unit. In fact, the total hospital costs were lower in the pericardiotomy group. In conclusion, posterior pericardiotomy is an effective and safe technique that reduces early pericardial effusion, atrial fibrillation, length of stay in hospital, and hospital costs after the coronary artery bypasses grafting.