The role of glomerular filtration rate in AVF success: Should we intervene earlier?

INTRODUCTION: End-stage kidney disease (ESKD) patients require life-sustaining kidney replacement therapies, with the natural arteriovenous fistula (AVF) being the preferred vascular access due to its low infection risk, high patency, and fewer complications. Factors like vessel diameter, gender, diabetes, age, and surgical technique influence AVF maturation. METHOD: Our study focused on short-term AVF creation success, specifically examining estimated glomerular filtration rate (eGFR) levels using the CKD-EPI formula. Patients were categorized according to their eGFR levels to observe the effects of fistula timing and the severity of kidney disease. RESULTS: No significant demographic or outcome differences between eGFR groups have been observed except for gender. AVF maturation was notably associated with distal vein diameter (>2 mm), while other factors did not significantly impact maturation rates. As a secondary outcome, it was concluded that the recording of patients' blood pressure values at preoperative and perioperative levels led to the conclusion that blood pressure levels may have an impact on fistula maturation. CONCLUSION: To ensure vascular access effectiveness, optimizing blood pressure, determining vein diameter, strategic AVF timing, and reducing catheter usage are crucial. Our study aimed to identify eGFR levels conducive to optimal AVF outcomes. Although significant results could not be obtained in this regard, it is considered worthwhile to re-examine the effect of blood pressure in secondary outcomes. Additionally, prospective studies may be appropriate for reevaluating the effect of GFR.

Comparison of Pericardial and Prosthetic Rings for Mitral Repair: Are Pericardial Rings Durable in the Mid- to Long-Term Follow Up?

BACKGROUND: While prosthetic rings are commonly used for mitral valve repairs, autologous pericardium is an alternative ring material that can be used in these procedures. In this report, we aim to present a comparison of two types of rings used for mitral repair. METHODS: Between January 2005 and January 2009, 107 patients who underwent mitral valve repair surgery were analyzed. Patients were divided into two groups, according to the type of ring that was used for mitral annular stabilization. Glutaraldehyde-treated pericardial rings were used for 31 patients (group 1), whereas prosthetic rings were used for 76 patients (group 2). Survival, freedom from reoperation, recurrent mitral regurgitation, and the effects of rheumatic mitral disease on these parameters were evaluated and compared for both groups. RESULTS: Follow-up time for our cohort was 4.24±0.4 years. There were four and seven late mortalities in groups 1 and 2, respectively, and five reoperations in each group. There was no significant difference between the groups, in terms of survival, freedom from reoperation, and recurrent mitral regurgitation (log-rank analyses for both groups were P = 0.777, P = 0.346, and P = 0.781, respectively). There was no significant difference in freedom from reoperation and recurrent mitral regurgitation for both groups, in terms of underlying rheumatic valvular disease and other types of pathology. CONCLUSION: Pericardial ring annuloplasty shows to be a considerable alternative technique for mitral valve repair procedures in the mid- to long-term follow up. Rheumatic mitral valves had poor outcomes, when compared with other types of structural valvular pathologies in cases where pericardial rings were used in the repair procedure.

Outcomes of arteriovenous fistula for hemodialysis in octogenarian population.

Introduction Guidelines have been recommending the use of arteriovenous fistula among the hemodialysis population, but no clear conclusion has emerged with regard to the adequate access type in octogenarians. In this paper, the outcomes of arteriovenous fistula in octogenarian cohort were presented for death-censored cumulative patency rate, complications, and patients' survival rate. Methods A retrospective review of 88 consecutive arteriovenous fistula interventions in 70 octogenarian patients were performed at one referral institution between January 2010 and June 2014. The patients' records were analyzed and postoperative complications were documented. Death-censored cumulative arteriovenous fistula patency rates were calculated, and Kaplan-Meier method was used to analyze patient survival for 24 months. FINDINGS: Eighty-eight arteriovenous fistula constructions and six salvage procedures were performed in 70 octogenarians. Fifty-four (61.3%) forearm and 34 (38.7%) upper arm fistulas were created. All types of fistulas had 6-, 12-, 18-, and 24-month death-censored cumulative patency rates of 63.6%, 58.3%, 48.8%, and 41.4%, respectively. The primary failure rate was 40.9%. A total of 15 complications were documented as edema, hematoma/bleeding, infection, distal ischemia, and venous aneurysm, all of which had been treated. Patient survival rates for 12 and 24 months were 68.5% and 58.5%, respectively. DISCUSSION AND CONCLUSION: This analysis regarding arteriovenous fistula in octogenarian end-stage renal disease patients figured out equal death-censored cumulative patency compared to nonelderly, and two-year survival rate was acceptable. This study strengthens the argument that arteriovenous fistula should be the best proper choice in selected octogenarians; older age only should not be considered as an absolute contraindication for arteriovenous fistula creation in octogenarians; and patient-based approach should be applied.

Recurrent Left Atrial Botyroid Rhabdomyosarcoma.

Primary heart tumors are extremely rare and their frequency ranges from approximately 0.01-0.3% in autopsy series. Nearly one quarter of all primary cardiac tumors are malignant tumors such as sarcoma. Rhabdomyosarcoma is the second most common malignant primary tumor of the heart following angiosarcoma.Primary cardiac tumors present with one or more of the symptoms of the classic triad: cardiac symptoms and signs resulting from intracardiac obstruction; signs of systemic embolization; and systemic or constitutional symptoms. The prognosis after surgery is usually excellent in case of benign tumors, but is unfortunately still limited in localized malignant diseases [Butany 2005].In this case report we present a 45-year-old female patient operated three times in 9 years because of left atrial tumor.

A rare coexistence: Poland's syndrome and cardiac angiosarcoma.

Poland's syndrome, a rare genetic disorder that accompanies malignancies, musculoskeletal disorders, cardiac and genitourinary syndromes. There is no study that represents the association between cardiac angiosarcoma and Poland's syndrome. A 24-year-old female patient previously diagnosed with Poland's syndrome was admitted to our hospital complaining of dyspnea. Diagnostic imaging showed an irregular mass in the right atrial cavity. After successful surgery, she was discharged uneventfully and the 3rd month oncologic follow-up reveals none of residual mass. The coexistence has not been diagnosed and treated in a cardiac surgery department before. With this presentation, we aimed to contribute to the literature with this presentation, for the right and early diagnosis and management of possible new cases in the future can be diagnosed and treated correctly and early.

Asymmetric dimethylarginine levels in Buerger's disease.

BACKGROUND: Endothelial dysfunction may play a major role in both peripheral arterial disease (PAD) and Buerger's disease (BD). Asymmetric dimethylarginine (ADMA) is an endogenous inhibitor of endothelial nitric oxide synthase and increased ADMA levels impair vascular homeostasis. We aimed to determine the plasma levels of ADMA and evaluate the relationship of ADMA levels with smoking and clinical severity of the disease in patients with BD and to compare these results with those of patients with PAD and healthy individuals. METHODS: In our center, 45 patients undergoing peripheral arterial surgery, 28 patients being followed up for BD, and 24 healthy individuals without vascular or cardiac disease, were enrolled in the study. Intra- and intergroup analysis was performed to evaluate the relationship of ADMA levels with smoking behaviors and clinical disease severity according to Fontaine classification. RESULTS: ADMA levels were 1.26 ± 0.76 mmol/L, 0.87 ± 0.27 mmol/L, and 1.07 ± 0.88 mmol/L in patients with PAD, in patients with BD, and in the control group, respectively. ADMA levels were significantly higher in patients with PAD than those in control patients (p = 0.003) and the levels observed in patients with BD were significantly lower than those in control patients (p = 0.001). Smokers with PAD had higher ADMA levels than smokers with BD (p = 0.03). ADMA levels were higher in patients with Fontaine stage III and IV disease than those with Fontaine stage II diseases, for patients with PAD as well as those with BD. CONCLUSION: The lower ADMA levels observed in patients with BD might be related to the degradation of ADMA by dimethylarginine dimethylaminohydrolase in response to ischemia and could act as a defensive mechanism during the acute or quiescent phases. In patients with BD experiencing severe clinical conditions or with a longer time course for the disease, higher ADMA levels may suggest a poor prognosis.

Increase in graft blood flow in the early postoperative period.

Flow has been suitably measured by transit-time flow measurement, but measurements in the early period after cardiopulmonary bypass do not reflect expected values because of several factors. We documented that flow measurements during immediate revision of bleeding increased 3 times for the left internal thoracic artery and 2 times for the saphenous vein graft over previous measurements made after cardiopulmonary bypass in a patient who underwent coronary artery bypass surgery.

Simultaneous operation in a patient with coronary heart disease, abnormal orifice of coronary arteries, morgagni hernia, atrial septal defect, and pericardial and pleural agenesis.

A 68-year-old male patient with acute coronary syndrome was referred to our center. He also received a diagnosis of diaphragmatic hernia after a clinical examination. The patient underwent a simultaneous aorta coronary bypass operation and repair of the congenital diaphragm hernia. During the operation, the patient was observed to have an atrial septal defect. Our handling of the case is discussed in light of the literature.

Ultrasonography-guided foam sclerotherapy in patients with small saphenous vein insufficiency.

PURPOSE: Chronic venous insufficiency is an important health problem; small saphenous vein (SSV) insufficiency is one of the leading causes and may affect up to 20% of adults. In addition to conventional treatment methods, endovenous treatment techniques have become popular in treatment of varicose veins. Herein, we report the outcomes of ultrasound-guided foam sclerotherapy (UGFS) in patients with symptomatic SSV insufficiency. METHODS: From January 2014 to June 2018, patients with primary SSV insufficiency treated with UGFS were followed to assess the effectiveness and safety of the procedure. A total of 31 lower limbs of 30 patients (18 females and 12 males), who attended control visits at 1 week, 1, 3, and 6 months, and yearly, after undergoing UGFS, were included in the study. The clinical results, occlusion rates, and the patients' preprocedure and postprocedure Venous Clinical Severity Scores were recorded. RESULTS: The records show that, during the procedure, severe pain occurred at the time of injection in one patient (3%), vasovagal syncope in one patient (3%), hyperpigmentation in five patients (16%), and phlebitis in three patients (9%). It was also recorded that during follow-up 24 legs (78%) showed complete thrombosis and 7 legs (22%) had partial thrombosis. The mean Venous Clinical Severity Score for the patients before UGFS was 8.58 ± 3.78, and 7.25 ± 3.17 after the procedure. No major complications, including sural nerve injury and deep venous thrombosis, were seen during the follow-up period. CONCLUSIONS: The results of this study show that UGFS is a simple, safe, and effective procedure for treatment in patients with symptomatic SSV insufficiency with acceptable side effects.

The role of clopidogrel and acetylsalicylic acid in the prevention of early-phase graft occlusion due to reactive thrombocytosis after coronary artery bypass operation.

BACKGROUND: Reactive thrombocytosis has been reported in 20% of patients after coronary artery bypass grafting (CABG), a frequency that might be related to the high incidence of thrombotic complications. The present study was planned to investigate the effect of combined treatment with clopidogrel and acetylsalicylic acid (ASA) on post-CABG reactive thrombocytosis. METHODS: Included in this prospective, randomized study were 60 patients who underwent CABG operation with a 6-month follow-up. Three study groups were defined: group 1 (n = 20), a control group of patients who have not developed reactive thrombocytosis after CABG surgery; group 2 (n = 20), patients who have developed reactive thrombocytosis and continue taking ASA (300 mg/day); and group 3 (n = 20), patients who have developed reactive thrombocytosis and continue taking ASA (300 mg/day) with the addition of clopidogrel (75 mg/day). RESULTS: The mean ages and sex distributions of the patient groups were similar. There were no significant differences between the groups regarding cardiovascular risk factors, baseline laboratory findings, or intraoperative characteristics. Thrombocytosis disappeared within the first month after the operation in both treatment groups. An evaluation of graft patency in the sixth postoperative month revealed that group 2 had significantly more patients with a "positive" result in the exercise test than group 3 and that group 3 had a lower incidence of graft occlusion than group 2 (P < .01). CONCLUSIONS: Combination antiplatelet therapy with ASA and clopidogrel seems to be more effective than ASA alone for maintaining graft patency in patients with reactive thrombocytosis.

Perioperative type I aortic dissection during conventional coronary artery bypass surgery: risk factors and management.

OBJECTIVES: Perioperative iatrogenic type I aortic dissection (PIAD) is a rare but potentially fatal complication of conventional coronary artery bypass surgery (CCABG). Prompt recognition and repair of PIAD may significantly improve outcomes. METHODS: We reviewed the hospital records of patients with PIAD occurring as a complication of CCABG at Siyami Ersek Thoracic and Cardiovascular Surgery Center from January 2001 through June 2007. During this period, 10,130 CCABG were performed and 21 patients (0.20%) with PIAD were identified. We compared variables for these 21 patients with 603 patients without PIAD (control group). RESULTS: PIAD occurred intraoperatively in 19 patients (90%) and during the early postoperative period (first 6 hours) in 2 patients (10%) who underwent CCABG. Dissections were noticed after removal of the aortic crossclamp in 11 patients, during aortic cannulation in 3 patients, and after removal of the partial-occlusion clamp in 5 patients. Patients with and without PIAD differed significantly in regard to sex (P = .05), history of hypertension (P = .001), and history of severe concomitant peripheral arterial disease (PAD) (P = .001). The diameter of the aorta was significantly wider in patients with PIAD. (3.83 +/- 0.9 vs 2.93 +/- 0.46 cm, P = .019). The occurrence of high cardiopulmonary bypass (CPB) pressure (>==120 mmHg) was significantly higher in the PIAD patients than the non-PIAD patients (28.6% vs 3.3%, P = .0001). Seven PIAD patients (33.3%) died preoperatively and 3 (14.2%) died postoperatively. CONCLUSION: PIAD is frequently fatal. Risk factors for PIAD during or after CCABG include female sex, history of PAD and hypertension, increased aortic diameter, and high CPB pressure.

Myocardial injury during off-pump surgery. The effect of intraoperative risk factors.

OBJECTIVE: To achieve better outcomes, the degree of myocardial injury due to off-pump coronary artery bypass surgery (OPCAB) must be reduced. We studied the factors that render patients scheduled for OPCAB vulnerable to myocardial injury, using troponin T (cTnT) as a marker of myocardial injury. METHODS: We prospectively investigated 123 patients being operated by a group of surgeons with off-pump technique between January 2001 and June 2006 in Siyami Ersek Thoracic and Cardiovascular Surgery Center. Myocardial injury occurring during surgery was assessed by post-operative cTnT measurement. Then, the relation between intraoperative factors and postoperative cTnT release were statistically evaluated. RESULTS: Blood samples for cTnT measurement were taken from all patients before operation, immediately after arrival at the intensive care unit, then at 6, 12, and 24 hours after distal revascularization. When regarding the intraoperative risk factors, we found that the heart rate, blood pressure and anastomosis time are the main determinant of myocardial cell injury occurring during OPCAB surgery. CONCLUSION: Although aortic cross-clamp and cardioplegic arrest were not used in off-pump myocardial revascularization, the ischemic myocardial cell destruction was also inevitable in off-pump technique. Therefore, management of heart rate and myocardial contractility was desirable not only for precise anastomosis but also for myocardial protection during OPCAB surgery.

Causes of Dyspnea after Cardiac Surgery.

OBJECTIVES: Postoperative dyspnea is common after cardiac surgery, even in low-risk patients. Cardiac surgeons and anesthesiologists are familiar with patients suffering from dyspnea in the early postoperative period, but in some cases, conventional treatment strategies may be ineffective, and a consultation with a pulmonologist may be required. The aim of this study is to investigate the causes of dyspnea after cardiac surgery in this particular patient group. MATERIALS AND METHODS: The hospital database was searched for non-emergency cardiac surgery for the period January 2014-October 2015. Individuals with an impaired spirometry result and a history of any pulmonic disease were excluded. Only patients for whom a pulmonary consultation was needed because of dyspnea in the postoperative course were enrolled in the study. Causes of dyspnea were analyzed according to consultation reports and computed tomography findings. RESULTS: One hundred and three patients were enrolled in the study. Of those, 67 (65%) were male, and the mean age was 61.50±9.43. The most common procedure was the coronary artery bypass grafting. Atelectasis (n=57, 42%) was the most common cause of dyspnea. The length of the intensive care unit (ICU) stay was significantly longer in the pneumonia group (p=0.012). Hospital mortality in the pneumonia group was significantly higher compared with other subgroups (p<0.001). CONCLUSION: After cardiac surgery, atelectasis was the most common cause of dyspnea, followed by pleural effusion and pneumonia. Patients who experienced dyspnea due to pneumonia had a longer ICU stay. Developing the treatment strategies with consideration of these causes may help reduce the length of stay, morbidity, and mortality in this patient group.

Right Sided Aortic Arch Resembling Asthma.

Exertional dyspnoea and shortness of breath at rest are common complaints in asthmatic patients. However, symptoms sometimes do not resolve under optimal medical treatment. In such cases infrequent causes of dyspnoea may be the underlying basis. We present a 38-year-old patient who suffered from shortness of breath not amenable to medical treatment for asthma for five years. In her medical history, the patient was on salbutamol inhalation as well as budesonide/formoterol inhalation for 5 years and the symptoms did not ameliorate. We diagnosed a right sided aortic arch after investigations. In this rare anomaly, both trachea and oesophagus might be encircled and compressed by large vessels as well as the aortic arch. Although some signs of right sided aortic arch can be recognized in chest radiograph and spirometry, accurate diagnosis is made by contrast enhanced computed tomography or angiography. Delay in diagnosis of right sided aortic arch may result in unnecessary investigations and prolonged periods of ineffective treatment. Diagnosis of right sided aortic arch leads to improvement in symptoms and withdrawal of unnecessary treatment.

Arterial Blood Gas Analysis in Chronic Obstructive Pulmonary Disease Patients Undergoing Coronary Artery Bypass Surgery.

OBJECTIVES: We aimed to investigate the impact of arterial blood gas (ABG) on morbidity and mortality in chronic obstructive pulmonary disease (COPD) patients undergoing CABG surgery. MATERIAL AND METHODS: The records for 75 COPD patients who underwent elective CABG surgery our institution clinic between November 2008 to 2011 and had a forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ≤ 70% value in the pulmonary function tests (PFT) performed prior to the surgery were evaluated retrospectively. COPD patients were divided into two groups; Group 1; FEV1 ≥ 60% and Group 2; FEV1 ≤ 59%. Groups were compared for mortality and adverse events after identification of other preoperative and postoperative factors that could affect mortality and adverse events. An ABG was obtained immediately before and 3 to 6 hours after surgery to study the predictive value of ABG in seperate COPD groups. RESULTS: There were no significant differences in patients with high partial pressure carbondioxide (PaCO2) preoperative values compared to patients with normal values. Also there were no significant differences in patients with lower partial pressure of oxygen (PaO2) preoperative values compared to patients with normal values in terms of mortality. Postoperative myocardial infarction (MI) was significantly higher in patients with low PaO2 values (p< 0.05). CONCLUSION: In conclusion, in our study, there could not be found a relation between the degree of preoperative obstruction and mortality for COPD patients who underwent CABG surgery. ABG was not found useful for predicting mortality in COPD patients undergoing CABG surgery, but could be useful to predict postoperative MI in patients with COPD.

Red blood cell distribution width is associated with early failure of arteriovenous fistula for haemodialysis access.

This study aimed to investigate the predictive value of red blood cell distribution width (RDW) for early failure of arteriovenous fistula (AVF) for haemodialysis access. The hospital records of those patients who underwent primary AVF creation procedures for haemodialysis between December 2010 and September 2013 were included for retrospective analysis. Of 313 patients, 195 (62%) were male and 118 (38%) were female. Mean age was 60 (range 17-90) years. Of the 313 AVF procedures performed, 229 (73%) were created at forearm (radial artery-cephalic vein), and 84 (27%) were created upperarm (antecubital, brachiocephalic, or brachiobasilic procedures). Early AVF failure was found in 61 (19%) patients. According to chi-square test, the incidence of early AVF failure was higher in patients with heart failure and peripheral artery disease (P < 0.001). According to Mann-Whitney U test, the RDW (P = 0.001) and C-reactive protein (P = 0.024) values were higher in patients with early AVF. Our data showed that preoperative RDW is a reliable parameter that can be useful in predicting the early failure of AVF.

Daily comparison of respiratory functions between on-pump and off-pump patients undergoing CABG.

OBJECTIVE: Widespread application of on-pump revascularization procedures is increasing due to the thought of elimination of untoward effects of cardiopulmonary circuit. Thus, whether off-pump coronary artery surgery eliminates side effects especially related to respiratory functions is still controversial. Although many previous studies have evaluated these respiratory functions, daily comparison of 12 parameters was not included in any of the studies. The aim of our prospective study was to ascertain whether off-pump coronary operation improves pulmonary functions and postoperative recovery period when compared with on-pump technique and whether early discharge of patients with off-pump surgery is the result of respiratory improvement. METHODS: Eighteen patients in each group were included: on-pump group underwent coronary revascularization with cardiopulmonary bypass and off-pump with stabilization. Respiratory function tests and arterial blood gas analyses were performed preoperatively and daily after operation function tests included forced expiratory volume (FEV) in 1s, forced vital capacity (FVC), expiratory reserve volume, vital capacity, quotient of FEV in 1s to FVC, maximal voluntary ventilation (MVV), tidal volume, and forced midexpiratory flow. Blood gas analyses included partial arterial oxygen and carbon dioxide pressure, arterial pH and hematocrit (Hct). RESULTS: Preoperative pulmonary functions and arterial blood gases were not statistically significant between groups except MVV and partial arterial oxygen pressure. MVV was slightly higher in on-pump group and partial arterial oxygen pressure was slightly lower in on-pump group. During postoperative first day Hct (P=0.004) and FEV in 1s (P=0.049) values and third day partial arterial oxygen pressure (P=0.011) and Hct (P=0.011) values were lower in on-pump group. Mean extubation, duration in postoperative suit and hospital discharge times, mean blood loss were not statistically significant between groups postoperatively. CONCLUSION: Pulmonary functions and arterial blood gases were not improved in off-pump patients when compared with on-pump patients. Patients going to be surgically revascularized should not be altered to off-pump surgery merely with the hope of improving respiratory functions with off-pump technique. As the postoperative stay times at surgical theatre and hospital is not different and the extubation times were similar, early discharge of patients with off-pump surgery cannot be related merely to better preservation of respiratory functions.

Computed tomography evaluation of different chest tube sites for residual pleural volumes after coronary artery bypass surgery.

BACKGROUND AND OBJECTIVES: We investigated the efficacy of pleural drainage with the use of different chest tube methods in patients after coronary artery bypass graft (CABG) surgery. DESIGN AND SETTING: Prospective randomized study of 60 patients undergoing elective on-pump single CABG surgery. PATIENTS AND METHODS: The left internal mammary arterial grafts were harvested from all patients. The patients were separated into three groups: In one group (IC6, n=20), pleural tubes were inserted through the sixth intercostal space at the midaxillary line; in the second group (SX-r, n=20), rigid straight pleural tubes were inserted from the mediastinum through the subxiphoid area; and in the third group (SX-s, n=20), soft curved drainage tubes were inserted from the mediastinum through the subxiphoid area. The residual pleural effusion was examined by multislice CT scans within 8 hours of removal of the drainage tubes. Pain was evaluated according to standard methods. RESULTS: The groups did not differ with respect to volume of residual pleural effusion (P >.05). The IC6 group had a higher mean pain score than the other two groups (P <.05), whose mean pain scores did not differ significantly from each other (P >.05). IC6 group patients had a higher requirement for analgesics. The rate of atelectasis was higher in group IC6 (P <.05). CONCLUSION: CT scans revealed that different chest tube insertion sites have the same efficiency for draining of pleural effusion, although drainage tubes inserted through the thoracic cage may result in more severe pain.