Short-term outcomes in adult cardiac surgery in the use of del Nido cardioplegia solution.

OBJECTIVES: Del Nido cardioplegia in adult cardiac surgery has not been studied although it has been in common use as a "single" dose cardioplegia in pediatric heart surgery. We retrospectively assessed the short-term (in-hospital) clinical outcomes of patients undergoing aortic valve replacement (AVR) using del Nido cardioplegia solution, comparing it to conventional multi-dose whole blood cardioplegia. METHODS: We switched our cardioplegia protocol from conventional whole blood cardioplegia exclusively to del Nido solution in May 2011. In 2011, 240 consecutive patients underwent isolated AVR. One hundred and seventy-eight of them were operated on with the use of del Nido cardioplegia (del Nido group) and whole blood cardioplegia (conventional group) was used in the other 62 patients. Isolated AVR was chosen as a cohort because of its relative simplicity and the similarity of surgical techniques among surgeons. Propensity-score matching identified 54 matched pairs for analysis. RESULTS: The retrograde cardioplegia technique was used in 19 cases (35.2%) in the del Nido group and 52 cases (96.3%) in the conventional group (p<0.001). Mean cardiopulmonary bypass time and mean aortic cross-clamp time were significantly shorter in the del Nido group compared to the conventional group: 71 ± 16 min vs. 84 ± 28 min (p<0.01), 52 ± 14 min vs. 60 ± 16 min (p<0.01), respectively. Postoperative inotropic support was required in 11 patients (20.4 %) in the del Nido group and 13 patients (24.1 %) in the conventional group (p=0.82) with no statistical difference. No patient required a postoperative intra-aortic balloon pump and in-hospital mortality was 0% in both groups. There was no significant difference in postoperative complications between the two groups. CONCLUSIONS: Short-term outcomes in adult cardiac surgery using del Nido solution were acceptable and comparable to conventional multi-dose whole blood cardioplegia. The del Nido cardioplegia technique was associated with shortened cross-clamp times and less frequent utilization of the retrograde cardioplegia delivery technique.

Attenuation of the unfolded protein response and endoplasmic reticulum stress after mechanical unloading in dilated cardiomyopathy.

Abnormal intracellular calcium (Ca(2+)) handling can trigger endoplasmic reticulum (ER) stress, leading to activation of the unfolded protein response (UPR) in an attempt to prevent cell death. Mechanical unloading with a left ventricular assist device (LVAD) relieves pressure-volume overload and promotes reverse remodeling of the failing myocardium. We hypothesized that mechanical unloading would alter the UPR in patients with advanced heart failure (HF). UPR was analyzed in paired myocardial tissue from 10 patients with dilated cardiomyopathy obtained during LVAD implantation and explantation. Samples from healthy hearts served as controls. Markers of UPR [binding immunoglobulin protein (BiP), phosphorylated (P-) eukaryotic initiation factor (eIF2α), and X-box binding protein (XBP1)] were significantly increased in HF, whereas LVAD support significantly decreased BiP, P-eIF2α, and XBP1s levels. Apoptosis as reflected by C/EBP homologous protein and DNA damage were also significantly reduced after LVAD support. Improvement in left ventricular dimensions positively correlated with P-eIF2α/eIF2α and apoptosis level recovery. Furthermore, significant dysregulation of calcium-handling proteins [P-ryanodine receptor, Ca(2+) storing protein calsequestrin, Na(+)-Ca(2+) exchanger, sarcoendoplasmic reticulum Ca(2+)-ATPase (SERCA2a), ER chaperone protein calreticulin] was normalized after LVAD support. Reduced ER Ca(2+) content as a causative mechanism for UPR was confirmed using AC16 cells treated with a calcium ionophore (A23187) and SERCA2a inhibitor (thapsigargin). UPR activation and apoptosis are reduced after mechanical unloading, which may be mediated by the improvement of Ca(2+) handling in patients with advanced HF. These changes may impact the potential for myocardial recovery.

Similar survival in patients following heart transplantation receiving induction therapy using daclizumab vs. basiliximab.

BACKGROUND: Induction therapy with interleukin-2 receptor antagonists has been established as an effective immunosuppressive strategy in the management of heart transplant (HTx) recipients. We compared outcomes following HTx in patients receiving basiliximab, daclizumab, or no induction therapy. METHODS AND RESULTS: We investigated post-transplant prognosis of patients receiving basiliximab (n=67), daclizumab (n=98) or no induction therapy (n=70). Patients treated with daclizumab (50.3 ± 14.7 years) were younger than those receiving basiliximab (55.8 ± 11.2 years) or no induction therapy (54.9 ± 14.1 years; both P<0.05). Patients receiving either induction therapy showed better survival 1 year after HTx (95%) than those without induction therapy (82%; P<0.001). Survival was similar between patients receiving basiliximab and daclizumab. The incidence of acute cellular or antibody-mediated rejections did not differ among the groups. The main reason that patients did not receive induction therapy was ongoing infection (65.7%), which was more common in patients on ventricular assist device (VAD) support than those without VAD (76.1% vs. 45.8%; P=0.004). The VAD-related infection rate in the entire study cohort was 29.7% (35/118 VAD recipients). CONCLUSIONS: Survival following HTx was worse in patients not receiving induction therapy. No differences were noted in survival or the incidence of rejection between the daclizumab- and basiliximab-treated groups. Induction therapy was less used in patients with infection, which was related to prior VAD support.

Acute kidney injury following surgical aortic valve replacement.

BACKGROUND: Acute kidney injury (AKI) is a significant complication of surgical aortic valve replacement (SAVR). This study sought to describe AKI following SAVR, its risk factors, predictors and effect on long-term survival. METHODS: We retrospectively reviewed 2169 patients who underwent isolated SAVR between 2000 and 2012. The main end-points were occurrence of AKI, postoperative complications, and short- and long-term survival rates following SAVR. Patients were divided into two groups: AKI+ (n = 181) and AKI- (n = 1945). RESULTS: AKI occurred in 8.5% of patients, of which 3.9% (n = 7) needed dialysis. Predictors of AKI after SAVR were body mass index (BMI) and intraoperative packed red blood cells (PRBC) transfusion. AKI+ patients had a more complicated postoperative course and higher cumulative mortality (25% vs. 17%, p = 0.012) with a median follow-up of 4.1 years. AKI was not found to be an independent predictor of mortality. CONCLUSIONS: Predictors of AKI after SAVR are increased BMI and intraoperative PRBC transfusion. AKI conferred an increase in hospital length of stay and cumulative mortality while the need for postoperative dialysis was associated with the most complicated hospital stays and the highest in-hospital and cumulative mortalities; therefore careful recognition of patients at risk of AKI is warranted for a better preoperative renal optimization. However, incidence of AKI was lower than what is reported after both on-CPB cardiac surgeries and transcatheter aortic valve replacement, moreover AKI was not found to be an independent predictor of mortality.

Residual Tricuspid Regurgitation following Tricuspid Valve Repair during Concomitant Valve Surgery Worsens Late Survival.

BACKGROUND: Concomitant tricuspid valve repair (TVr) for functional tricuspid regurgitation (TR) at the time of left-sided valve surgery has become increasingly more common over the past decade. The impact of residual post-repair TR on late outcomes remains unclear. METHODS: All patients undergoing TVr during concomitant left-sided valve surgery at our institution from 2005-2012 were retrospectively reviewed. Patients were stratified into 2 groups according to the degree of post-cardiopulmonary bypass TR observed on intraoperative transesophageal echocardiography; 0-1+ TR (No TR, n = 246) and ≥2+ TR (Residual TR, n = 26). Primary outcomes of interest were 30-day survival, 4-year survival, and follow-up TR grade. A propensity-matched subgroup analysis was performed in addition to the overall cohort analysis. RESULTS: Mean age for all patients was 70.3 ± 13.0 years and 107 (39%) patients were male. There was no difference in 30-day survival between groups (92% No TR versus 96% Residual TR, P = .70). Kaplan-Meier analysis of overall 4-year survival showed a trend toward worsened survival in the Residual TR group (log rank P = .17) and propensity-matched subgroup analysis showed significantly worse 4-year survival for Residual TR (log rank P = .02). At mean echocardiographic follow up of 11.9 ± 22.5 months, TR grade was significantly worse in the Residual TR group compared to No TR (1.5 ± 0.8 Residual TR versus 0.9 ± 0.9 No TR, P = .005), although TR severity was significantly improved from immediately post-bypass. CONCLUSIONS: Patients left with residual TR following TVr during concomitant left-sided valve surgery have significantly decreased late survival compared to patients left with no post-repair TR.

Myocardial protection using del nido cardioplegia solution in adult reoperative aortic valve surgery.

BACKGROUND AND AIMS: The immediate postischemic period is marked by elevated intracellular calcium levels, which can lead to irreversible myocyte injury. Del Nido cardioplegia was developed for use in the pediatric population to address the inability of immature myocardium to tolerate high levels of intracellular calcium following cardiac surgery. Our aim in this study is to determine if this solution can be used safely and effectively in an adult, reoperative population. METHODS: All patients undergoing isolated reoperative aortic valve replacement at our institution from 2010 to 2012 were retrospectively reviewed. Demographics, comorbidities, operative variables, postoperative complications, and patient outcomes were collected. Patients were divided into two groups based on cardioplegia strategy used: whole blood cardioplegia (WB, n = 61) and del Nido cardioplegia (DN, n = 52). RESULTS: Mean age in the study was 73.4 ± 14.3 years and 86 patients were male (76.1%). Eighty-four patients had undergone prior coronary artery bypass graft (CABG) (74.3%). Patients in the DN group required significantly lower total volume of cardioplegia (1147.6 ± 447.2 mL DN vs. 1985.4 ± 691.1 mL WB, p < 0.001) and retrograde cardioplegia dose (279.3 ± 445.1 mL DN vs. 1341.2 ± 690.8 mL WB, p < 0.001). There were no differences in cross-clamp time, bypass time, postoperative complication rate, or patient outcomes between groups. CONCLUSIONS: Del Nido cardioplegia use in an adult, reoperative aortic valve population offers equivalent postoperative outcomes when compared with whole blood cardioplegia. In addition, use of del Nido solution requires lower total and retrograde cardioplegia volumes in order to achieve adequate myocardial protection.

Acute type-A aortic dissection with obstruction of the right coronary artery.

Occlusion of a coronary artery by an acute type A aortic dissection presents a life-threatening emergency that is rarely seen and easy to misdiagnose. We present the case of a 75-year-old male who experienced sudden onset of severe left-sided chest pain due to an acute type A aortic dissection that obstructed the right coronary artery. Following an initial misdiagnosis of acute coronary syndrome, imaging revealed the presence of an aortic dissection. An emergency modified Bentall procedure was performed, in which the damaged aorta and aortic valve were replaced.

Simultaneous beating heart coronary artery bypass surgery and modified radical mastectomy.

Concomitant surgeries for unrelated diseases can be performed to minimize the risks associated with surgery and general anesthesia. In treating a male patient with breast cancer and severe coronary artery disease, we used the beating heart technique for a coronary artery bypass graft to avoid the negative effects of on-pump bypass on the possible acceleration of tumor growth. In this report, we present a unique case of concomitant off-pump coronary artery bypass graft surgery and modified radical mastectomy in a 56-year-old man.

Extrinsic compression of the left main coronary artery: a case of atrial septal defect with enlarged pulmonary artery.

We report the case of an adult referred to our center with an initial diagnosis of stenosis of the left main coronary artery (LMCA). A preoperative investigation disclosed an atrial septal defect (ASD) with pulmonary artery hypertension. The angiographic studies confirmed the diagnosis and showed external compression of the LMCA by an enlarged pulmonary artery. Surgical closure of the ASD and tricuspid valve ring annuloplasty with coronary artery bypass surgery (left internal mammary artery to left anterior descending artery) were undertaken. Six months after the surgery, the patient is doing well.

Prosthetic valve implantation with preservation of the entire valvular and subvalvular apparatus of the tricuspid valve in congenitally corrected transposition of the great arteries.

Congenitally corrected transposition of the great arteries, which is characterized by atrioventricular and ventriculoarterial discordance, is a rare congenital heart disease. Most of the cases are diagnosed in childhood, owing to associated cardiac anomalies, such as ventricular septal defect, pulmonary stenosis or pulmonary atresia, and Ebstein-like malformation of the tricuspid valve. We present a patient with congenitally corrected transposition of the great arteries who underwent surgical replacement of the tricuspid valve with a bioprosthesis and reconstruction of the left ventricular outflow tract with bovine conduit.

Investigation of Circulating miRNA-133, miRNA-26, and miRNA-378 as Candidate Biomarkers for Left Ventricular Hypertrophy.

BACKGROUND/AIM: Left ventricular hypertrophy (LVH) involves increased muscular mass of the left ventricle due to increased cardiomyocyte size and is caused by cardiomyopathies. Several microRNAs (miRNAs) have been implicated in processes that contribute to heart disease. This study aimed to examine miRNA-133, miRNA-26 and miRNA-378 as candidate biomarkers to define prognosis in patients with LVH. PATIENTS AND METHODS: The study group consisted of 70 patients who were diagnosed with LVH and 16 unaffected individuals who served as the control group. Real-time polymerase chain reaction (RT-PCR) was used to analyze serum miRNA-133, miRNA-26, and miRNA-378 expression levels in LVH patients and the control group. Receiver operating characteristic (ROC) curve analysis was performed to assess the diagnostic capability of miRNA-378. RESULTS: When crossing threshold (CT) values were compared between patient and control samples, we found that there were no statistically significant differences in miRNA-133 and miRNA-26 CT values, while the miRNA-378 expression was significantly increased in LVH patients. ROC analysis demonstrated that the expression levels of miRNA-378 (AUC=0.484, p=0.0013) were significantly different between groups. CONCLUSION: We observed a statistically significant relationship between miRNA-378 expression levels and LVH, suggesting that circulating miRNA-378 may be used as a novel biomarker to distinguish patients who have LVH from those who do not.

A new practical alternative for the control of sternal bleeding during cardiac surgery: Ankaferd Blood Stopper.

The control of sternal bleeding during cardiac surgery can sometimes be a challenging and time-consuming problem for surgeons. Several alternatives for the control of sternal bleeding are on the market. Bone wax is a well-known alternative used by many cardiac surgeons for the control of bleeding. It is effective and cheap; however, it inhibits ossification of the sternum and can cause infections and sternal wound healing problems after cardiac surgery. Consequently, control of sternal bleeding without the use of bone wax requires meticulous preparation. Ankaferd Blood Stopper (ABS) (Ankaferd Saglik Ürünleri, Istanbul, Turkey) is a unique folkloric medicinal plant extract that has been used in Turkish traditional medicine as a hemostatic agent. We present a practical alternative technique for the control of sternal bleeding during cardiac surgery with the use of ABS.

First Turkish experiences of assisted beating-heart coronary artery bypass graft with the Impella Microaxial Ventricular Assist Device.

The importance of minimally invasive cardiac operations, performed off-pump, without the support of cardiopulmonary bypass (CPB), is continuously increasing. Complete revascularization of obstructed coronary arteries is needed to obtain a better long-term outcome. Insertion into the left ventricle of an efficient microaxial pump can be useful when targeting an important coronary artery located at posterior wall of the heart in a patient with hemodynamic deficiency. The use of such a device can enable surgeons to avoid conversion from a preplanned off-pump strategy to traditional on-pump coronary bypass surgery. The Impella Microaxial Ventricular Assist Device (VAD) (Abiomed, Aachen, Germany) is a miniature pump with a 7-mm catheter and a flow rate of approximately 2.5-5 L/min. This device can enable cardiovascular surgery to be performed without damaging the left ventricle and causing serious aortic deficiency. Therefore, in patients with serious comorbidity, complete revascularization may be performed off pump, with the heart beating, because of the hemodynamic stability provided with the support of the microaxial intracardiac pump. If required, this pump can also support the heart during the early postoperative period. We report the first assisted beating-heart coronary artery bypass graft surgery performed with the Impella Microaxial VAD in our country. The surgery was performed on 2 patients considered high risk on the basis of EUROSCORE testing.

Surgical treatment of a bronchial cyst causing compression to the left atrium and pulmonary artery.

Bronchogenic cysts that formed during the development of the tracheobronchial tree in the gestational period are mostly asymptomatic until adulthood. Cysts localized in the middle mediastinum, specifically in the subcarinal region, on the other hand, may cause serious symptoms by compressing the heart and major vessels due to their close proximity. In this report it is suggested that surgical resection of a giant bronchogenic cyst that compresses the heart and great vessels should be securely performed in the presence of a readily available cardiopulmonary bypass capability.

High-risk left main coronary artery bypass surgery supported by the Impella Recover LP 2.5 assist device: an alternative insertion technique.

Patients with high-risk coronary lesions such as left main stenosis and a severely depressed left ventricular ejection fraction are at risk of death and morbidity-related complications during coronary artery bypass surgery. Several alternative methods have been developed for managing this problem, but it is still challenging, even for highly experienced and well-equipped cardiac surgery centers. We report the case of a successful coronary artery bypass surgery supported by the Impella Recover LP 2.5 assist device and using an alternative insertion technique for the ascending aorta in a patient with high-risk coronary lesions, such as left main disease.

Sarcoidosis and coronary bypass surgery: a case report.

Sarcoidosis, a chronic granulomatous disease with unknown etiology and pathogenesis, affects the skin and many other organs and has a course characterized by remissions and relapses. We describe a patient with sarcoidosis, which we diagnosed retrospectively after we had difficulties in harvesting the left internal thoracic artery because of giant and disseminated mediastinal lymphadenopathies on the anterior thoracic wall during urgent coronary artery bypass surgery.

Is isolated aortic valve replacement sufficient to treat concomitant moderate functional mitral regurgitation? A propensity-matched analysis.

BACKGROUND: A significant proportion of patients presenting for isolated aortic valve replacement (AVR) demonstrate some degree of functional mitral regurgitation (fMR). Guidelines addressing concomitant mitral valve intervention in those patients with moderate fMR lack strong evidence-based support. Our aim is to determine the effect of untreated moderate fMR at the time of AVR on long-term survival. METHODS: All patients undergoing isolated AVR from 2000 to 2013 at our institution were retrospectively reviewed. Patients were stratified according to severity of preoperative fMR; 0-1+ MR (Group NoMR, n = 1826) and 2-3+ MR (Group MR, n = 330). All patients in Group MR were propensity-matched with patients in Group NoMR to control for differences in baseline characteristics. The primary outcome of interest was overall survival. RESULTS: Propensity analysis matched 330 patients from each group. Mean age was 77.9 ± 10.0 years and 50.6% were male. There were no differences in baseline demographics, echocardiographic parameters, or co-morbidities between groups. Kaplan-Meier analysis showed significantly worse medium and long-term survival in Group MR compared to Group NoMR (log-rank p = 0.02). Follow-up echocardiography showed slightly more severe MR in Group MR (1.1 ± 0.7 MR vs. 0.8 ± 0.7 NoMR, p = 0.03) at 1 year. CONCLUSIONS: Patients undergoing isolated AVR with concomitant 2-3+ fMR experience poorer long-term survival than those patients with no or mild fMR. This suggests that mitral valve intervention may be necessary in patients undergoing AVR with clinically significant fMR.

Effects of Two Current Great Saphenous Vein Thermal Ablation Methods on Visual Analog Scale and Quality of Life.

BACKGROUND: The aim of the study is to compare the current two endovenous thermal ablation methods by examining the effects on the visual analog scale (VAS) and the short form-36® quality of life index. METHODS: Ninety-six patients who underwent unilateral endovenous thermal ablation of great saphenous vein were included. ClosureFast™ catheters were used in the RFA group and 1470 nm radial fiber laser catheters were used in the EVLA group. RESULTS: The RFA group consisted of 41 patients and the EVLA group consisted of 55 patients. The preoperative baseline characteristics of both groups were similar. On the day of operation, VAS values were 2.8 ± 1.1 in the RFA group and 3.6 ± 1.8 in the EVLA group (p = 0.02). Comparisons of short form-36 parameters in both groups showed them to be similar except the pain detected at postoperative 1st week (48.1 ± 5.4 for RFA, 44.9 ± 7.6 for EVLA, p = 0.04). CONCLUSION: Results in postprocedural quality of life were found to be similar in both of the techniques. However, in terms of postoperative pain, radiofrequency ablation is still superior to the 1470 nm radial fiber laser catheters.

Mid-calf level as a puncture site is not safe enough for thermal ablation of the small saphenous vein.

BACKGROUND: Endovenous thermal ablation of the small saphenous vein carries a risk for sural nerve injury. Ablation above mid-calf level is recommended to avoid it. However, this strategy could not eradicate this complication. We present our results of consecutive 30 small saphenous vein thermal ablations which are performed after ultrasonographic identification of the sural nerve. METHODS: We studied 26 consecutive subjects with a total of 30 limbs. Ablation was performed proximal to the risk point by a 1470-nm diode laser. Patients were asked to attend follow-up outpatient controls at 7 days, 30 days, and 180 days postoperatively. Rate of identification of the sural nerve by ultrasonography, safety of the mid-calf level as a puncture site and postoperative sural nerve damage were assessed. RESULTS: The sural nerve identification was achieved by ultrasonography in all patients except for one. Mid-calf level as a puncture site was not safe in three (10%) extremities. None of the patients showed any evidence suggesting postoperative sural nerve damage. CONCLUSION: Choosing the puncture site according to the risk point may be more reasonable than general mid-calf level which is being used.

Feasibility and safety of continuous retrograde administration of Del Nido cardioplegia: a case series.

BACKGROUND: Del Nido (DN) cardioplegia, a calcium-free, hyperkalemic solution containing lidocaine and magnesium has been developed to help reduce intracellular calcium influx and the resulting myocyte damage in the immediate postischemic period following cardiac arrest. DN cardioplegia has been used for pediatric cardiac surgery but its use in complex reoperative surgery has not been studied. We specifically report the outcomes of patients undergoing reoperative cardiac surgery after previous coronary artery bypass grafting with a patent internal mammary artery (IMA). METHODS: Patients undergoing reoperative cardiac surgery with prior coronary bypass grafting surgery were studied between 2010 and 2013. Fourteen patients were identified who required continued retrograde cardioplegia administration. In all cases, an initial antegrade dose was given, followed by continuous retrograde administration. Demographics, co-morbidities, intra-operative variables including cardioplegia volumes, post-operative complications, and patient outcomes were collected. RESULTS: The mean age of all patients was 73.3+/-6.7 years, and 93 % were male. Aortic cross clamp time and cardiopulmonary bypass times were 81+/-35 and 151+/-79 mins, respectively. Antegrade, retrograde and total cardioplegia doses were 1101+/-398, 3096+/-3185 and 4367+/-3751 ml, respectively. An average of 0.93+/-0.92 inotropes and 1.50+/-0.76 pressors were used on ICU admission after surgery. ICU and total hospital lengths of stay were 5.5+/-7.4 and 9.6+/-8.0 days, respectively. Complications occurred in two patients (14 %) (pneumonia and prolonged mechanical ventilation) and new arrhythmias occurred in five patients (36 %) (four new-onset atrial fibrillation and one pulseless electrical activity requiring 2 min of chest compression). No perioperative myocardial infarctions were noted based on electrocardiograms and cardiac serum markers. Postoperatively, left ventricular function was preserved in all patients whereas two patients (14 %) had mild decrease in right ventricular function as assessed by echocardiography. No mortality was observed. CONCLUSION: Del Nido cardioplegia solution provides acceptable myocardial protection for cardiac surgery that requires continuous retrograde cardioplegia administration. DN cardioplegia's administration in a continuous retrograde fashion with a patent IMA is believed to provide adequate myocardial protection while avoiding injuring the IMA through dissection and clamping.