Atrial Fibrillation after Coronary Bypass Surgery? Is Epicardial Fat a Risk Factor?

BACKGROUNDS: Postoperative atrial fibrillation (POAF) is one of the most common complication of cardiac surgery. Epicardial fat tissue may play a role in the development of atrial fibrillation (AF). The aim of this study was to evaluate relationship between epicardial fat volume (EFV) and the appearance of new-onset AF in patients undergoing isolated coronary artery bypass graft (CABG) with normal echocardiographic functions. METHODS: Between January 2017 and June 2020, 281 coronary artery disease patients undergone isolated CABG surgery with normal echocardiographic functions were included in the study. Patient characteristics, medical history, and perioperative variables were retrospectively collected. Patients with AF predisposition factors were excluded. RESULTS: Sixty-seven patients (23.8%) developed postoperatively AF during hospital stay. In univariate analysis, patients with postoperative AF were older compared with sinus rhythm patients (60.78 ± 9.03 vs. 65.46 ± 9.22, p = 0.001). There are no statistically significant differences between groups and EFV compared (107.78 ± 41.04 vs. 106.66 ± 34.98 p = 0.84). Large left atrial diameter, female patient, cardiopulmonary bypass and longer cross-clamp time showed correlation between POAF without statistical significance. CONCLUSION: Aging is the only associated factor with AF in this study. There was no EFV difference between POAF and non-AF groups in patients undergoing isolated CABG with normal echocardiographic functions.

Carotid artery stenosis in asymptomatic patients undergoing coronary artery bypass grafting: who and when should be screened?

BACKGROUND: Carotid artery stenosis (CAS) is one of the major causes of stroke in coronary artery bypass grafting (CABG). AIMS: The aim of this study was to determine which age groups require screening for CAS using carotid duplex ultrasound in asymptomatic patients undergoing CABG. METHODS: We included 644 neurologically asymptomatic consecutive patients (mean [SD] age, 63.9 [8.8] years; men, 453 [70.3%]) who underwent elective isolated CABG between June 2015 and June 2020. Clinical, demographic, and radiological data as well as coronary angiography results were retrospectively reviewed. Patients were classified into 4 age groups: 40 to 50, 51 to 60, 61 to 70, and >70 years, as well as 3 groups depending on the CAS degree: 50% or less, 50% to 70%, and 70% or greater. Regression analysis was applied across the selected parameters to identify risk factors for significant CAS, and receiver operating characteristic analysis, to determine cutoff age and SYNTAX score of patients who had to be screened before CABG. RESULTS: Overall, 8 (1.1%) patients included in the present study had stroke following CABG. Cutoff values of the SYNTAX score and CAS of 70% or greater were found to be 27 and 64 years, respectively. The sensitivity and specificity of the cutoff value were 98.4% to 98.3% and 74.3% to 55.1%, respectively. The area under the curve was 0.98 and 0.73, respectively. CONCLUSION: Based on the receiver operating characteristic analysis, we recommended to perform screening for CAS in patients older than 64 years and with a SYNTAX score of 27 or higher, even if they are asymptomatic.

Successful long-term limb salvage using cephalic and small saphenous vein grafts: A case report.

In this case report, we present a patient scheduled for operation due to critical leg ischemia in whom a bilateral great saphenous vein (GSV) had already been used during previous cardiac and peripheral vascular surgeries. The patient underwent femorofemoral crossover bypass from left to right with a small saphenous vein and right femoropopliteal bypass with cephalic vein (CV) during the same session. Distal pulses became palpable, and symptoms regressed dramatically following the operation. A control computed tomographic angiography scan revealed no signs of graft stenosis 32 months after the surgery. Despite the recent advances in synthetic graft materials, small saphenous and CVs should be remembered as alternative long-standing conduits in the absence of the GSV.

Comparison of Anterior Mitral Leaflet Repair Techniques with and without the Use of Chordal Replacement in Patients with Degenerative Mitral Valve Insufficiency.

BACKGROUND: The aim of our study was to compare the outcome of patients who underwent mitral valve anterior leaflet repair with and without chordal replacement for degenerative mitral valve insufficiency. METHODS: This study was conducted at our center between May 2006 and May 2013. The study included 125 patients with degenerative mitral valve insufficiency (64 males, 61 females; mean age 47 years, age range 16-78 years) who underwent mitral valve repair with anterior leaflet procedures. The patients were divided into 2 groups. Group A consisted of 56 patients with chordal replacement, and group B consisted of 69 patients with other repair techniques performed. RESULTS: No significant difference was determined between the 2 groups in mortality, recurrence, and reoperation rates. The mortality rate was 3.6% in group A and 1.4% in group B. During the follow-up period, 3 patients were reoperated on (mitral valve replacement) because of severe mitral valve insufficiency. Two of these patients were from group A (3.6%), and the other was from group B (1.4%). One patient in group A underwent intraoperative mitral valve replacement after unsuccessful chordal replacement. Fifty patients (89.3%) in group A and 65 patients (94.2%) in group B exhibited no or mild recurrence of mitral valve insufficiency. CONCLUSION: Mitral valve repair in patients with degenerative mitral valve insufficiency resulting from anterior leaflet pathology is a safe procedure because of its durability and good long-term results. Despite the difficulty of the chordal replacement procedure, it may be used as an alternative technique for anterior mitral valve leaflet repair.

Predictive Value of STOP-BANG on OSAS-Related Complications Following Coronary Artery Bypass Grafting.

BACKGROUND: The time and conditions may not be suitable for performing polysomnography (PSG) before urgent or emergent surgeries, for example, a coronary artery bypass graft. Unavailability in many centers, critical clinical situation, and inability to arrange a timely scheduled appointment are other limitations for PSG. In this study, we aimed to investigate if the STOP-BANG Questionnaire may predict obstructive sleep apnea syndrome (OSAS) related postoperative pulmonary alterations during coronary artery surgery. METHODS: Sixty-one subjects who were scheduled to undergo elective isolated coronary artery bypass graft surgery and were consulted for preoperative pulmonary assessment were recruited to the study. The STOP-BANG Questionnaire was used with the subjects; then their relationship with postoperative complications was assessed. RESULTS: Results of the STOP-BANG Questionnaire revealed that 36.1% of subjects were at high risk for OSAS. Three groups were established according to the STOP-BANG Questionnaire (low risk, group 1; moderate risk, group 2; high risk, group 3) and study parameters, including PEEP value in ventilator, detection of apnea at ventilator, CPAP time after extubation, SpO2 1 h after extubation, postoperative hypoxemia, need for CPAP, and ICU length of stay revealed significant relationships among these groups. CONCLUSIONS: The STOP-BANG Questionnaire may predict the OSAS risk and OSAS-related pulmonary complications for patients who are candidates for a coronary artery bypass graft and unable to be evaluated with PSG before surgery due to technical or time-related limitations.

Distribution of Thoracic Aortic Calcifications in Patients Undergoing Coronary Artery Bypass Grafting.

BACKGROUND: In procedures involving surgical maneuvers such as cannulation, clamping, or proximal anastomosis where aortic manipulation is inevitable, a preliminary assessment of atherosclerotic plaques bears clinical significance. In the present study, our aim was to evaluate the frequency and distribution of aortic calcifications in patients undergoing coronary artery bypass grafting (CABG) surgery to propose a morphological classification system. METHODS: A total of 443 consecutive patients with coronary artery disease were included in this study. Preoperative non-contrast enhanced computed tomography images, in-hospital follow-up data, and patient characteristics were retrospectively evaluated. RESULTS: Whereas 33% of patients had no calcifications at any site in the aorta, 7.9%, 75.4%, and 16.7% had calcifications in the ascending aorta, aortic arch, and descending aorta, respectively. Focal small calcifications were the most common type of lesions in the ascending aorta (3.9%), whereas 9 patients (1.4%) had porcelain ascending aorta. We defined four types of patients with increasing severity and extent of calcifications. CONCLUSIONS: Based on the frequency and distribution of calcifications in the thoracic aorta, we propose a classification system from least to most severe for coronary artery disease patients who are candidates for CABG.

A practical and inexpensive proximal anastomosis technique in calcified aorta.

Patients with severely calcified aorta have high risk of atheroemboli and bleeding during cardiac surgery. Clamping the ascending aorta to initiate cardiac arrest or to perform proximal anastomosis is a challenging problem. Beating heart coronary artery bypass grafting without aortic clamping is usually accepted as the best solution. Herein, we present a feasible and inexpensive proximal anastomosis technique without using aortic clamps for patients with severely atherosclerotic aorta.

Pentamidine in Pneumocystis jirovecii prophylaxis in heart transplant recipients.

Despite advances in transplantation techniques and the quality of post-transplantation care, opportunistic infections remain an important cause of complications. Pneumocystis jirovecii (P. jirovecii) is an opportunistic organism, represents an important cause of infections in heart transplantation patients. Almost 2% to 10% of patients undergoing cardiac transplantation have Pneumocystis pneumonia. Prophylaxis is essential after surgery. Various prophylaxis regimes had been defined in past and have different advantages. Trimethoprim/sulfamethoxazole (TMP/SMX) has a key role in prophylaxis against P. jirovecii. Generally, although TMP/SMX is well tolerated, serious side effects have also been reported during its use. Pentamidine is an alternative prophylaxis agent when TMP/SMX cannot be tolerated by the patient. Structurally, pentamidine is an aromatic diamidine compound with antiprotozoal activity. Since it is not effectively absorbed from the gastrointestinal tract, it is frequently administered via the intravenous route. Pentamidine can alternatively be administered through inhalation at a monthly dose in heart transplant recipients. Although, the efficiency and safety of this drug is well studied in other types of solid organ transplantations, there are only few data about pentamidine usage in heart transplantation. We sought to evaluate evidence-based assessment of the use of pentamidine against P. jirovecii after heart transplantation.

Angina severity predicts worse sleep quality after coronary artery bypass grafting.

OBJECTIVE: We sought to reveal whether the severity of angina pectoris affects sleep quality after elective coronary artery bypass grafting. MATERIAL AND METHODS: Patients scheduled to undergo isolated coronary artery bypass grafting were divided into two groups, having a recent myocardial infarction (Group 1, n=22, mean age 59.40±7.79 years) or not having a recent myocardial infarction (Group 2, n=30, mean age 59.73±7.72 years). The assessment included the Canadian Cardiovascular Society Angina Score, the visual analogue scale for postoperative pain and the Pittsburgh Sleep Quality Index (PSQI). RESULTS: The two groups were similar in regard to baseline characteristics. Cross-clamp time was significantly higher (p=0.007) and the use of inotropes was significantly more common (p=0.01) in those patients with recent myocardial infarction compared to those without. Mean Canadian Cardiovascular Society scores were also higher in patients with recent myocardial infarction (p=0.02). Total Pittsburgh Sleep Quality Index score was significantly higher in patients with recent myocardial infarction (8.45±3.50 vs. 5.03±2.32, respectively, p<0.001). In multivariate analysis, higher angina score (OR: 3.27, 95% CI, 1.20-8.90, p=0.02) and longer time of intensive care unit stay (OR: 6.15, 95% CI, 1.49-25.35, p=0.01) were found to be independent predictors of poor sleep quality. The Canadian Cardiovascular Society angina score showed a significant positive correlation with poor sleep duration score (<0.001), sleep disturbance score (p=0.02), day dysfunction due to sleepiness score (p=0.001), sleep efficiency score (p=0.003), overall sleep quality score (0.03) and total PSQI score (p=0.004). CONCLUSION: The severity of angina pectoris in the preoperative period is independently associated with worse sleep quality after elective isolated coronary artery bypass surgery.

Dopamine Administration is a Risk Factor for Delirium in Patients Undergoing Coronary Artery Bypass Surgery.

BACKGROUND: Delirium is an important morbidity following heart surgery. We sought to determine whether dopamine infusion is associated with increased risk of delirium in patients undergoing coronary artery bypass grafting. METHODS: A total of 137 patients (mean age; 61.02±7.83, 105 males) were included in the study. Patients undergoing isolated coronary artery bypass grafting were considered eligible and those with preoperative neurological deficit or significant neurocognitive disorders, dementia or psychiatric disorders were excluded. Primary outcome measure was occurrence of delirium within 72 hours after operation. The diagnosis of delirium was made using confusion assessment method for the intensive care unit questionnaire. Both administration of dopamine as a dichotomised variable and the total amount of dopamine per kg body-weight were included in two different logistic regression models. RESULTS: Delirium occurred in 18 (13.1%) patients. Age adjusted Mantel-Haenszel relative risk for delirium with receiving dopamine was 4.62. Relative risk was 2.37 (0.18 to 31.28, 95% CI, p=0.51) in total doses over 10mg whereas it was 3.55 (1.16 to 10.89 95% CI, p=0.02) in total doses over 30 mg per kg body-weight. Older age (p=0.03), dopamine administration (OR: 9.227 95% CI, 2.688-32.022, p<0.001) and the amount of dopamine administered (OR: 1.072, 95% CI, 1.032-1.115, p<0.001) were independent predictors for delirium 72 hours after surgery. CONCLUSION: Along with older age, dopamine infusion--even in low doses but more probably in higher doses--emerged as an independent risk factor for delirium in patients undergoing CABG. Further study is needed to confirm the validity of results presented.

Early Mortality and Long-term Survival after Repair of Post-infarction Ventricular Septal Rupture: An Institutional Report of Experience.

BACKGROUND: To determine predictors of mortality after surgical management of post-infarction ventricular septal rupture repair. METHODS: A total of 63 patients (73.2%, mean age 67.22±7.71 years, male:female ratio; 35:28) underwent open heart surgery for post-infarction ventricular septal rupture repair. Patient demographics, operative data and postoperative parameters were analysed to reveal predictors of early mortality and long-term survival. RESULTS: In-hospital mortality was 54.0% (34/63). Time from myocardial infarction to operation ≤ 14 days (OR: 4.10, 95% CI 1.16-14.46, p=0.02), systolic pulmonary artery pressure > 45 mmHg (OR: 4.14, 95% CI 1.110-15.496, p=0.03) and age (years) (OR: 1.09, 95% CI 1.002-1.194, p=0.04) were found to be independent predictors of in-hospital mortality. In multivariate Cox regression analysis, presence of pulmonary oedema on admission (HR: 4.95, 95% CI 1.58-15.54, p=0.006), age (years) (HR: 1.09, 95% CI 1.009-1.180, p= 0.02) and cross-clamp time <60 min (HR: 3.93, 95% CI 1.13-13.64, p=0.03) were found to be independent predictors of long-term survival. Within a follow-up of a median of 60.0 months, five-year survival rate was 67±9.0%. CONCLUSION: In line with the previous studies, our study demonstrated the benefits of delaying the repair for post-infarction ventricular septal rupture to allow adequate myocardial healing if haemodynamic status of the patient allows.

Effect of Left Atrial Reduction on Restoration and Maintenance of Sinus Rhythm in Patients Undergoing Mitral Valve Replacement: A Pilot Study.

Background This pilot study aimed to evaluate the effectiveness of posterior left atrial wall plication (T-plasty) in patients with persistent atrial fibrillation (AF) (> 7 days) undergoing mitral valve surgery. Materials and Methods A total of 60 patients who were scheduled for mitral valve replacement were randomly allocated into two groups: one would receive (Group 1; n = 32, mean age; 49.37 ± 9.00) and one would not receive (Group 2; n = 28; mean age 48.64 ± 8.6) left atrial size reduction using T-plasty technique. Patients with a clear indication for combined procedures other than tricuspid valve disease, aortic valve disease, and coronary artery stenosis were not included. Follow-up was performed at 6th, 12th, and 18th months after the operation. Results After the operation, 21 patients (65.6%) in Group 1 and 13 patients (46.4%) in Group 2 regained sinus rhythm (p = 0.13). Mortality did not occur. AF recurrence rates were not significantly different between the groups in three follow-ups. Restoration of sinus rhythm was significantly more common in Group 1 patients than in Group 2 patients during follow-up. Patients in Group 1 had lower left atrial volume indexes than those in Group 2 at the 6th and 12th months, whereas the difference at the 18th month was at the limit of significance. Conclusion We achieved satisfactory results using the T-plasty technique for left atrial size reduction in terms of mid-term restoration and preservation of normal sinus rhythm in patients undergoing mitral valve surgery. Further study may be justified to reveal the prognostic importance of the technique described herein.

Hyponatremia Due to Escitalopram and Thiazide Use After Cardiac Surgery.

Depression and mood disorders occur commonly following emergent cardiac surgery. Selective serotonin reuptake inhibitors are commonly used antidepressants. We report the development of severe hyponatremia leading to adverse clinical effects due to escitalopram and thiazide diuretic use concomitantly in a patient with depression after emergency coronary artery bypass grafting.

New Cutting Method to Aid Performance of Graft-to-Graft Aortic Anastomosis.

In graft-replacement surgery of the ascending aorta and aortic arch, 2 separate grafts are frequently needed in order to construct a more physiologically configured aorta. We describe a new cutting method for accurate performance of graft-to-graft anastomosis.

Groin Swelling in a Four-Year-Old Boy: Primary Great Saphenous Vein Aneurysm.

Primary venous aneurysm, especially in pediatric population, is a very rare clinical entity. We report a case of primary great saphenous vein aneurysm in a 4-year-old boy. He was initially suspected of suffering from inguinal hernia because the soft mass was detected at the inguinal region when the patient was in the standing position, but color Doppler ultrasonography demonstrated the swelling to be a great saphenous vein aneurysm. We decided that surgery was the best option because of potential risk for thromboembolism.

Use of a superficial femoral artery autograft as a femoral vein replacement.

Posttraumatic arteriovenous fistulas (AVFs) are common complications of vascular penetrating trauma. Here we present a case of a 59-year-old woman who had a history of gunshot injury 42 years ago causing AVF between superficial femoral artery (SFA) and superficial femoral vein (SFV). SFV was resected. Ipsilateral SFA was used to restore SFV. SFA was reconstituted using a 7-mm polytetrafluorethylene graft. The patient has normal venous and arterial flow at 3- and 15-month follow-up.

Relationship of admission neutrophil-to-lymphocyte ratio with in-hospital mortality in patients with acute type I aortic dissection.

AIM: Acute aortic dissection is a life-threatening cardiovascular emergency. Neutrophil-to-lymphocyte ratio is proposed as a prognostic marker and found to be related to worse clinical outcomes in various cardiovascular diseases. The aim of the present study was to evaluate the relationship between admission neutrophil-to-lymphocyte ratio and in-hospital mortality in acute type I aortic dissection. MATERIALS AND METHODS: We retrospectively evaluated 123 consecutive patients who had undergone emergent surgery for acute type I aortic dissection. Patients were divided into 2 groups as patients dying in the hospital (Group 1) and those discharged alive (Group 2). All parameters, including neutrophil-to-lymphocyte ratio, were compared between the 2 groups and predictors of mortality was estimated by using multivariate analysis. RESULTS: A total of 104 patients (79 males, mean age: 55.2 + 14 years) were included in the final analysis. In multivariate analyses, cross- clamp time, cardiopulmonary bypass time, intensive care-unit duration, platelet count, and neutrophil-to-lymphocyte ratio were found to be independent predictors of mortality. Patients with higher neutrophil-to-lymphocyte ratios had a significantly higher mortality rate (hazard ratio: 1.05; 95% CI: 1.01-1.10; P = 0.033). Receiver operating characteristic analysis revealed that using a cut-off point of 8, neutrophil-to-lymphocyte ratio predicts mortality with a sensitivity of 70% and specificity of 53%. CONCLUSION: This study suggests that admission neutrophil-to-lymphocyte ratio is a potential predictive parameter for determining the in-hospital mortality of acute type I aortic dissection.

Long-term patency of autogenous saphenous veins vs. PTFE interposition graft for prosthetic hemodialysis access.

OBJECTIVE: Prosthetic vascular access is the other choice when the superficial venous system is inadequate to perform a simple radio-cephalic and brachio-cephalic fistula. METHODS: This paper reports the outcomes of a prospective cohort study of 54 patients who underwent either saphenous vein (SVI Group, n=29) or PTFE graft (PTFE Group, n=25) interposition surgery for prosthetic hemodialysis access. All patients were evaluated via color Doppler ultrasonography during preoperative course and superficial venous systems of these patients were found inadequate to perform simple radial/brachial artery-cephalic vein anastomosis. Follow-up was performed for every 6-months period. Kaplan-Meier analysis and Log Rank test was used for estimation and comparison of the patency. RESULTS: In SVI group access failure was observed in 5 of 29 patients (17.2%). In PTFE group, access failure was observed in 13 of the 25 patients (52%). Primary patency rate was 93% in 12th month and 82% in 24th month in SVI group while it was 88% in 12th month and 56% in 24th month in PTFE group. According to the Kaplan-Meier method, mean time of primary patency was significantly higher in SVI group when compared to PTFE group (33.03±1.32 months vs. 28.16±1.91 months, Log Rank chi-square value: 7.01, df:1, p=0.008). Secondary patency rate was 96% in 12th month and 93% in 24th month for SVI group while 96% in 12th month and 84% in 24th month for PTFE group. According to the Kaplan-Meier method, mean time of secondary patency was significantly higher in SVI group when compared to PTFE group (34.27±0.95 months vs. 31.16±1.40 months, Log Rank chi-square value: 7.33, df:1, p=0.007). CONCLUSION: Autologous saphenous vein can be preferably chosen as a prosthetic hemodialysis access graft due its higher primary and secondary patency, lower complication rate and cost when compared with PTFE grafts.

Surgical strategy for moderate ischemic mitral valve regurgitation: repair or ignore?

BACKGROUND: Ischemic heart disease is a significant complication of atherosclerosis. Myocardial infarction after the development of coronary artery disease can lead to a number of serious complications, including ischemic mitral regurgitation (IMR). Currently there is no consensus regarding the preferred therapeutic modality for moderately severe IMR. In this study, the postoperative outcome of concomitant coronary artery bypass (CABG) and mitral valve repair was compared with that of CABG alone in two groups of patients with moderately severe IMR. METHODS: A total of 84 patients who underwent operations for coronary artery disease and moderately severe IMR were included in the study. Preoperative demographic and clinical characteristics were recorded at the time of admission. The severity of mitral regurgitation was graded using transthoracic echocardiography and left ventriculography. RESULTS: Significant postoperative improvements were observed in ejection fraction and systolic diameter compared to preoperative values (P = .006 and P = .020 respectively, in the intervention group, P = .001 and P = .001 respectively, in the control group). The decrease in pulmonary artery pressure (PAP) was significant only in the intervention group (P = .001). There was a significantly marked reduction in the severity of IMR in the intervention group compared to control. CONCLUSION: Surgical repair of the mitral valve in conjunction with CABG for moderately severe IMR appears to be more effective than isolated CABG for certain outcome parameters, including decreased severity of mitral regurgitation and decreased pulmonary artery pressure.

Surgical treatment of post-infarct left ventricular pseudoaneurysm with on-pump beating heart technique.

Left ventricular pseudo-aneurysms develop when cardiac rupture is contained by pericardial adhesions or scar tissue due to myocardial infarction, surgery, trauma or infection. Left ventricular pseudo-aneurysms are uncommon, difficult to diagnose and prone to cardiac rupture. Urgent surgical repair is recommended. Here we report on a case of a large left ventricular pseudo-aneurysm on the anterolateral wall due to a previous anterior myocardial infarction, and its successful repair using the on-pump beating-heart technique.