Management of Intramyocardial Dissecting Hematoma Following Myocardial Infarction.

Intramyocardial dissecting hematoma (IDH) is a rare condition mostly seen following acute myocardial infarction, chest trauma, and cardiac surgery. It is described as an incomplete rupture caused by hemorrhagic dissection within the myocardium, rather than extending to the epicardial layer. Management strategies for IDH are controversial due to limited reports. We present a case of a 61-year-old man diagnosed with IDH, left main, and three-vessel disease, subsequently treated surgically.

Identifying the optimal monopolar electrocautery output power in pedicular internal thoracic artery harvesting: 20 or 40 watts?

BACKGROUND: Monopolar electrocautery is an important tool for harvesting the pedicular internal thoracic artery (ITA) in cardiac surgery. The different power outputs of cautery may affect graft integrity and long-term patency. This study aimed to identify the optimal threshold of electrocautery power for ITA harvest. METHODS: This prospective study included 30 patients who underwent elective coronary artery bypass surgery at the Medipol Mega University Hospital. The ITA was harvested by monopolar electrocautery after a median sternotomy. The output of cautery was adjusted at 20 W in group A and 40 W in group B. Three to 4 cm of a distal ITA sample from each patient was examined under a light microscope by two independent pathologists. RESULTS: The ITA harvest time was longer in group A (21.2 ± 7.5 vs 10.3 ± 8.1 min, p < 0.001) than in group B. ITA free flow was similar in the two groups (43.6 ± 48.7 vs 51.7 ± 45.0 Ml/min, p = 0.762). Mild to moderate injury in the endothelial and sub-endothelial sample was more frequent in the low-cautery group (p = 0.0037). CONCLUSIONS: ITA endothelial integrity was found to be better preserved with 40W electrocautery. Moreover, 20W of monopolar electrocautery may not be safe in pedicular ITA harvesting.

Aortic aneurysm evaluation by scanning acoustic microscopy and Raman spectroscopy.

Aortic aneurysm is observed as a result of the extensive alteration in the elasticity of the aortic wall due to the breakdown of elastin and collagen. In this study, we studied the feasibility of scanning acoustic microscopy (SAM) and Raman spectroscopy (RS) in characterizing the dilated segments of the aorta from male and female patients with aortic aneurysm. SAM determined the acoustic property variation in the aorta by calculating the acoustic impedance values of aorta samples of 18 patients. RS determined the disease states by analyzing the chemical variation especially in the peaks related to elastin and collagen using the k-means classification method. Consequently, we assume that combining these two techniques in clinics will help to investigate the dilated segment of the aorta with micrometer resolution, which will reduce the possibility of new aneurysm formation due to a segment not excised during the surgery.

Efficiency of Prophylactic Ablation of the Tributary Venous Pathways Draining Around the Saphenofemoral Junction to Decrease the Rate of Future Varicose Vein and Symptoms Occurence.

BACKGROUND: There are various other collaterals draining into the venous system around the saphenofemoral junction in addition to the great saphenous vein. We aimed to determine the efficiency of prophylactic ablation of tributary veins in long term varicose vein and symptom recurrence. METHODS: Two hundred and sixty-three consecutive patients whom underwent radiofrequency ablation therapy for the treatment of superficial venous reflux disease were investigated. There were 129 patients who received isolated great saphenous vein ablation (Group A) where as 134 patients underwent ablation of the other tributary veins in addition to the great saphenous vein (Group B) between June 2015 and January 2017. The tributary superficial veins; refluxing and/or not refluxing, draining into the saphenofemoral junction were selectively catheterized and ablated in Group B. Patients are followed at least 1 year after the procedures regulary and researched for recurrence of varciose veins and symptoms. RESULTS: Gender, mean age, body mass index, diameter of the great saphenous veins, small saphenous vein disease, and grade of deep venous insufficiency did not differ significantly between the two groups. The mean number of tributary veins were similar in both groups (n: 1.9 ± 0.4 in Group A vs. n: 1.8 ± 0.7 in Group B) which were detected preoperatively as well as during the procedure. The mean number of ablated tributary venous pathways could be 1.4 ± 0.6 in Group B. During the follow up period symptoms related with varicose veins recurred in 19 patients in Group A where as in 7 patients in Group B (P < 0.05). Three of these symptomatic patients in Group B were the ones in whom the tributary pathways could not be catheterized ablated where as 14 patients in Group A were diagnosed with newly refluxing tributary pathways. All the symptomatic patients in both groups were managed medically and/or with additional interventions. CONCLUSION: The absence of any fascial unsheathing and the parietal weakness are suggestive of a lower resistance of the tributary veins wall, so collapse and size of veins make it more complex to catheterization regarding to great saphenous vein. Ablation of the tributary superficial venous pathways during the treatment of great saphenous vein reflux disease decreased the rate of recurrence of superficial venous reflux disease and patients symtoms in our modest cohort.

Preoperative Arterial and Venous Cannulation in Redo Cardiac Surgery: From the Safety and Cost-effectiveness Points of View.

OBJECTIVE: To investigate the safety and cost-effectiveness of preoperative cannulation and conventional approach techniques. METHODS: Sixty-one patients who underwent redo open cardiac procedures between September 2015 and November 2018 were divided into two groups - Group A (n: 30), patients who underwent conventional cannulation after sternotomy, and Group B (n: 31), those who underwent cannulation before sternotomy. Patients were evaluated retrospectively for general complication rates and total hospital costs. RESULTS: Mortality occurred in four patients from Group A and in one patient from Group B. Four patients required extracorporeal membrane oxygenation (ECMO) in Group A, whereas two required ECMO in Group B. Duration of total operation, cardiopulmonary bypass, and cross-clamp times were longer in the conventional surgery group than in the pre-sternotomy cannulation group (420.29±188.84 vs. 314.77±187.38, P=0.036; 171.87±85.59 vs. 141.7±82.47, P=0.089; and 102.94±70.67 vs. 60.97±52.81, P=0.009; respectively). Total blood and blood product usage were higher in Group A than in Group B. Postoperative intensive care unit stay was 62.77±145.3 hours vs. 25.13±73.11 hours, ventilation time was 5.16±5.09 hours vs. 3.03±2.78 hours, duration of ward stay was 5.23±2.52 days vs. 5.57±2.16 days, and duration of hospital stay was 9.58±5.85 days vs. 9.8±5.31 days in conventional sternotomy and pre-sternotomy cannulation groups, respectively. Total hospital costs were calculated 35863.52±20803.99 Turkish Liras (TL) in Group A and 25744.74±16472.03 TL in Group B (P=0,042). CONCLUSION: Venous and arterial cannulations before sternotomy decreased myocardial injury and complication rates, blood and blood product usage, hospital stay, and, consequently, hospital costs in our modest cohort.

Preoperative arterial and venous cannulation in redo cardiac surgery: from the safety and cost-effectiveness points of view

Abstract Objective: To investigate the safety and cost-effectiveness of preoperative cannulation and conventional approach techniques. Methods: Sixty-one patients who underwent redo open cardiac procedures between September 2015 and November 2018 were divided into two groups - Group A (n: 30), patients who underwent conventional cannulation after sternotomy, and Group B (n: 31), those who underwent cannulation before sternotomy. Patients were evaluated retrospectively for general complication rates and total hospital costs. Results: Mortality occurred in four patients from Group A and in one patient from Group B. Four patients required extracorporeal membrane oxygenation (ECMO) in Group A, whereas two required ECMO in Group B. Duration of total operation, cardiopulmonary bypass, and cross-clamp times were longer in the conventional surgery group than in the pre-sternotomy cannulation group (420.29±188.84 vs. 314.77±187.38, P=0.036; 171.87±85.59 vs. 141.7±82.47, P=0.089; and 102.94±70.67 vs. 60.97±52.81, P=0.009; respectively). Total blood and blood product usage were higher in Group A than in Group B. Postoperative intensive care unit stay was 62.77±145.3 hours vs. 25.13±73.11 hours, ventilation time was 5.16±5.09 hours vs. 3.03±2.78 hours, duration of ward stay was 5.23±2.52 days vs. 5.57±2.16 days, and duration of hospital stay was 9.58±5.85 days vs. 9.8±5.31 days in conventional sternotomy and pre-sternotomy cannulation groups, respectively. Total hospital costs were calculated 35863.52±20803.99 Turkish Liras (TL) in Group A and 25744.74±16472.03 TL in Group B (P=0,042). Conclusion: Venous and arterial cannulations before sternotomy decreased myocardial injury and complication rates, blood and blood product usage, hospital stay, and, consequently, hospital costs in our modest cohort.

Peripheral vs. Central Cannulation in Cardiac Reoperations: Technical Considerations and Outcomes.

OBJECTIVE: To compare peripheral and central cannulation techniques in cardiac reoperation. METHODS: This retrospective study included 258 patients undergoing cardiac reoperation between January 2013 and July 2018. Patients were divided into two groups according to the cannulation type. The first group included 145 (56.2%) patients operated with standard central cannulation through aorta and right atrium or bicaval cannulation. In this group, cardiopulmonary bypass was instituted after sternotomy. The second group consisted of 113 (43.8%) patients operated with peripheral cannulation through femoral artery, vein, and internal jugular vein. In this group, cardiopulmonary bypass was started before sternotomy and after systemic heparinisation. The two groups' operative complications and postoperative outcomes were compared. RESULTS: Procedure-related injury was higher in the central cannulation group than in the peripheral cannulation group (8.3% vs. 1.8%, respectively, P=0.038). Cardiopulmonary bypass time was shorter in the central cannulation group (P=0.008) and total operation time was similar between the groups (P=0.115). Postoperative red blood cell requirement was higher with central cannulation (P=0.004). Operative mortality (2.8% vs. 0, P=0.186), hospital mortality (4.3% vs. 2.7%, P=0.523), and one-year survival rate (90.3% vs. 94.7%, P=0.202) were similar between the groups. CONCLUSION: Peripheral cannulation reduces cardiac injury and blood transfusion in cardiac reoperation. The cannulation type does not affect postoperative complication, mortality, and one-year survival.

Peripheral vs. central cannulation in cardiac reoperations: technical considerations and outcomes

Abstract Objective: To compare peripheral and central cannulation techniques in cardiac reoperation. Methods: This retrospective study included 258 patients undergoing cardiac reoperation between January 2013 and July 2018. Patients were divided into two groups according to the cannulation type. The first group included 145 (56.2%) patients operated with standard central cannulation through aorta and right atrium or bicaval cannulation. In this group, cardiopulmonary bypass was instituted after sternotomy. The second group consisted of 113 (43.8%) patients operated with peripheral cannulation through femoral artery, vein, and internal jugular vein. In this group, cardiopulmonary bypass was started before sternotomy and after systemic heparinisation. The two groups' operative complications and postoperative outcomes were compared. Results: Procedure-related injury was higher in the central cannulation group than in the peripheral cannulation group (8.3% vs. 1.8%, respectively, P=0.038). Cardiopulmonary bypass time was shorter in the central cannulation group (P=0.008) and total operation time was similar between the groups (P=0.115). Postoperative red blood cell requirement was higher with central cannulation (P=0.004). Operative mortality (2.8% vs. 0, P=0.186), hospital mortality (4.3% vs. 2.7%, P=0.523), and one-year survival rate (90.3% vs. 94.7%, P=0.202) were similar between the groups. Conclusion: Peripheral cannulation reduces cardiac injury and blood transfusion in cardiac reoperation. The cannulation type does not affect postoperative complication, mortality, and one-year survival.

Giant aneurysm of the non-coronary sinus of Valsalva

Abstract Aneurysms of the sinuses of Valsalva are defined as dilatation of the aortic root region between the aortic annulus and the sinotubular junction. Isolated aneurysms of the sinus of Valsalva are rare cardiovascular pathologies. They may be congenital, especially secondary to connective tissue disorders or in conjunction with congenital cardiac defects, or acquired such as secondary to infections or trauma. Small sized aneurysm without rupture in asymptomatic patients may be followed; however, latter cases require intervention and surgery is the gold standard treatment modality. In this report, a 41-year-old male patient was reported with giant aneurysm of the non-coronary sinus of Valsalva whom underwent aortic root sparing surgical aortic sinus of Valsalva reconstruction.

Congenital cardiac interventions during the peak phase of COVID-19 pandemics in the country in a pandemics hospital in Istanbul.

INTRODUCTION: In this report, we aim to present our algorithm and results of patients with congenital cardiac disorders who underwent surgical or interventional procedures during the peak phase of the pandemics in our country. PATIENTS AND METHODS: The first COVID-19 case was diagnosed in Turkey on 11 March, 2020, and the peak phase seemed to end by the end of April. All the patients whom were referred, treated, or previously operated but still at the hospital during the peak phase of COVID-19 pandemics in the country were included into this retrospective study. Patient's diagnosis, interventions, adverse events, and early post-procedural courses were studied. RESULTS: Thirty-one patients with various diagnoses of congenital cardiovascular disorders were retrospectively reviewed. Ages of the patients ranged between 2 days and 16 years. Seventeen cases were males and 14 cases were females. Elective cases were postponed. Priority was given to interventional procedures, and five cases were treated percutaneously. Palliative procedures were preferred in patients whom presumably would require long hospital stay. Corrective procedures were not hesitated in prioritised stable patients. Mortality occurred in one patient. Eight patients out of 151 ICU admissions were diagnosed with COVID-19, and they were transferred to COVID-19 ICU immediately. Three nurses whom also took care of the paediatric cases became infected with SARS-CoV-2; however, the children did not catch the disease. CONCLUSION: Mandatory and emergent congenital cardiac percutaneous and surgical procedures may be performed with similar postoperative risks as there are no pandemics with meticulous care and preventive measures.

A surgical technique for ascending aorta, aortic arch and descending aorta replacement without cross-clamp, circulatory arrest or hypothermia.

Treatment of the aneurysms comprising the aortic arch is challenging. Surgical reconstruction usually requires aortic cross-clamping, cardiac arrest, and even deep hypothermia for a bloodless field. In this report, we present our surgical technique providing normothermic ascending aorta, aortic arch, and proximal descending aorta replacement with selective cannulation and perfusion of the whole body.

Giant Aneurysm of The Non-Coronary Sinus of Valsalva.

Aneurysms of the sinuses of Valsalva are defined as dilatation of the aortic root region between the aortic annulus and the sinotubular junction. Isolated aneurysms of the sinus of Valsalva are rare cardiovascular pathologies. They may be congenital, especially secondary to connective tissue disorders or in conjunction with congenital cardiac defects, or acquired such as secondary to infections or trauma. Small sized aneurysm without rupture in asymptomatic patients may be followed; however, latter cases require intervention and surgery is the gold standard treatment modality. In this report, a 41-year-old male patient was reported with giant aneurysm of the non-coronary sinus of Valsalva whom underwent aortic root sparing surgical aortic sinus of Valsalva reconstruction.

Left ventricular assist device implantation combined with bentall procedure

Abstract Ventricular assist devices (VADs) are an important technological development for patients with end-stage heart failure, and approximately 50% of these patients require various additional cardiac procedures. Here we presente the case of a patient suffering from severe aortic insufficiency, aortic root dilatation, and an ascending aortic aneurysm with end-stage decompensated heart failure. We performed the Bentall procedure combined with a left VAD implantation during the same session. The postoperative period was uneventful for this patient, and he was discharged on the 32nd postoperative day. The heart failure symptoms of the patient are reasonable, and he is still on the heart transplantation waiting list.

Left Ventricular Assist Device Implantation Combined with Bentall Procedure.

Ventricular assist devices (VADs) are an important technological development for patients with end-stage heart failure, and approximately 50% of these patients require various additional cardiac procedures. Here we presente the case of a patient suffering from severe aortic insufficiency, aortic root dilatation, and an ascending aortic aneurysm with end-stage decompensated heart failure. We performed the Bentall procedure combined with a left VAD implantation during the same session. The postoperative period was uneventful for this patient, and he was discharged on the 32nd postoperative day. The heart failure symptoms of the patient are reasonable, and he is still on the heart transplantation waiting list.

A Study Demonstrating the Quantitative Relationship Between Internal Thoracic Artery Length and Free Flow.

BACKGROUND: The left internal thoracic artery (LITA) is the most commonly used arterial bypass conduit in coronary artery bypass graft (CABG) patients and inadequate LITA flow can result in an increase in morbidity and mortality. In this study, we evaluated the effect of excision of the distal spasmodic segment of the LITA on the free flow in CABG patients. METHODS: This study consisted of 47 patients who underwent elective CABG performed with or without other cardiac surgery, between July 2015 and December 2015. Excised LITA length was shorter than 15mm in group 1, between 15mm and 30mm in group 2 and longer than 30mm in group 3. Left ITA free flow was measured for 60seconds into a container before and after the distal LITA excision. The inter-measurement differences were calculated for the three groups. Thereafter, the comparison was performed in terms of free flow difference amongst the three groups. RESULTS: The mean difference of LITA free flow was 27.6±22.7ml/minute in group 1, 35.4±26.7ml/minute in group 2, and 52.6±26.1ml/minute in group 3. There were significant differences in terms of free flow difference between the groups (p=0.008). Also, differences were statistically significant in group 1 versus group 3 (p=0.003) and group 2 versus group 3 (p=0.038) in the intergroup comparisons. CONCLUSIONS: The distal part of the LITA has more spasmodic potential than other segments. This spasm may result in low flow of LITA grafts. Therefore, an as long as possible excision of the distal LITA segment may be required to avoid the spasmodic effect.

Prognostic Value of Neutrophil to Lymphocyte Ratio and Risk Factors for Mortality in Patients with Stanford Type A Aortic Dissection.

BACKGROUND: Neutrophil to lymphocyte ratio (NLR) is a prognostic predictor in a wide range of cardiovascular disease. Acute aortic dissection (AD) is an uncommon but fatal cardiovascular disease. In this study, we investigated both prognostic factors in patients with AD and whether NLR can be a predictor for mortality. Methods: We analyzed retrospectively the data of 57 patients with AD who had undergone emergent surgery in our hospital and included 128 consecutive patients with chest pain admitted to the emergency room as a control group. Also, patients who were operated on due to aortic dissection as another subgroup were compared to NLR values. Baseline clinical features, cardiovascular risk factors, and surgical and laboratory parameters were obtained from the hospital database. Results: Patients with AD had higher NLR than the control group (1.7 ± 0.5 versus 7.6 ± 3.3, P < .001). In the AD group, 15 deaths occurred and non-survivors had significantly higher NLR, compared to survivors (11.6 ± 2.4 versus 6.6 ± 2.3, P < .001). In multivariate analysis, high NLR (odds ratio [OR] 1.913, 95% CI 1.030-1.081, P = .04) and cross-clamp time (OR 1.265, 95% CI 1.003-1.596, P = .04) were determined as independent predictors of in-hospital mortality. In receiver operating characteristics curve analyses, the NLR > 9.3 predicted the mortality in AD with a specificity of 91% and a sensitivity of 86% (P < .001). CONCLUSION: This study shows that high NLR can be used as a marker for prognosis in short-term mortality of patient with AD. Additionally, increased lactate level in perioperative period, prolonged cardiopulmonary bypass time, and additional cardiac procedures are strong independent predictors of short-term mortality in patients with acute AD.

Robotic resection of giant left ventricular myxoma causing outflow tract obstruction.

We report a 38-year-old female, who presented with progressive dyspnea and fatigue. Echocardiography revealed a giant and freely mobile left ventricular myxoma causing left ventricular outflow tract (LVOT) obstruction. The patient underwent totally endoscopic robotic excision of a giant left ventricular myxoma. The tumor was completely removed through the mitral valve orifice with a left atriotomy incision.

Patient body image, self-esteem, and cosmetic results of minimally invasive robotic cardiac surgery.

BACKGROUND: Patient-reported outcome measures reveal the quality of surgical care from the patient's perspective. We aimed to compare body image, self-esteem, hospital anxiety and depression, and cosmetic outcomes by using validated tools between patients undergoing robot-assisted surgery and those undergoing conventional open surgery. MATERIALS AND METHODS: This single-center, multidisciplinary, randomized, prospective study of 62 patients who underwent cardiac surgery was conducted at Hospital from May 2013 to January 2015. The patients were divided into two groups: the robotic group (n = 33) and the open group (n = 29). The study employed five different tools to assess body image, self-esteem, and overall patient-rated scar satisfaction. RESULTS: There were statistically significant differences between the groups in terms of self-esteem scores (p = 0.038), body image scores (p = 0.026), overall Observer Scar Assessment Scale (p = 0.013), and overall Patient Scar Assessment Scale (p = 0.036) scores in favor of the robotic group during the postoperative period. Robot-assisted surgery protected the patient's body image and self-esteem, while conventional open surgery decreased these levels but without causing pathologies. Preoperative depression and anxiety level was reduced by both robot-assisted surgery and conventional open surgery. The groups did not significantly differ on Patient Satisfaction Scores and depression/anxiety scores. CONCLUSION: The results of this study clearly demonstrated that a minimally invasive approach using robotic-assisted surgery has advantages in terms of body image, self-esteem, and cosmetic outcomes over the conventional approach in patients undergoing cardiac surgery.