Acute normovolemic hemodilution in cardiac surgery: Rationale and design of a multicenter randomized trial.

BACKGROUND: Minimizing the use of blood component can reduce known and unknown blood transfusion risks, preserve blood bank resources, and decrease healthcare costs. Red Blood Cell (RBC) transfusion is common after cardiac surgery and associated with adverse perioperative outcomes, including mortality. Acute normovolemic hemodilution (ANH) may reduce bleeding and the need for blood product transfusion after cardiac surgery. However, its blood-saving effect and impact on major outcomes remain uncertain. METHODS: This is a single-blinded, multinational, pragmatic, randomized controlled trial with a 1:1 allocation ratio conducted in Tertiary and University hospitals. The study is designed to enroll patients scheduled for elective cardiac surgery with planned cardiopulmonary bypass (CPB). Patients are randomized to receive ANH before CPB or the best available treatment without ANH. We identified an ANH volume of at least 650 mL as the critical threshold for clinically relevant benefits. Larger ANH volumes, however, are allowed and tailored to the patient's characteristics and clinical conditions. RESULTS: The primary outcome is the percentage of patients receiving RBCs transfusion from randomization until hospital discharge, which we hypothesize will be reduced from 35% to 28% with ANH. Secondary outcomes are all-cause 30-day mortality, acute kidney injury, bleeding complications, and ischemic complications. CONCLUSION: The trial is designed to determine whether ANH can safely reduce RBC transfusion after elective cardiac surgery with CPB. STUDY REGISTRATION: This trial was registered on ClinicalTrials.gov in April 2019 with the trial identification number NCT03913481.

Outcomes of conservative management in patients with nutcracker syndrome.

OBJECTIVE: This study aims to evaluate outcomes in nutcracker syndrome patients with tolerable symptoms and treated conservatively without invasive interventions. METHODS: This prospective study included patients treated conservatively. Promoting weight gain, the endpoint of the study was spontaneous resolution of symptoms. RESULTS: Sixteen patients (75% female and mean age 24.4 ± 3.5 years) underwent conservative management. Over a mean follow-up of 27.3 months [13-42, interquartile range (IQR)], the diameter ratio (5.5 [5-6.5, IQR] vs 4.3 [4.1-6], p = NS), the peak velocity ratio (6 [5-7, IQR] vs 4.8 [4.8-5.8], p = NS), beak angle (27° [24-30, IQR] vs 29° [24-32]; p = NS), and aortomesenteric angle (26° [23-29, IQR] vs 28° [24-30]; p = NS) exhibited no statistically significant changes. Complete resolution and improvement of symptoms were 28.5% and 31.4%, respectively, while 68.5% remained unchanged. CONCLUSIONS: This study shows that a conservative approach contributes to the spontaneous improvement or complete resolution in young adult patients with mild symptoms.

Treatment of Nutcracker Syndrome with Left Renal Vein Transposition and Endovascular Stenting.

BACKGROUND: Nutcracker syndrome is a rare condition that occurs as a result of the entrapment of the left renal vein (LRV) between the aorta and the superior mesenteric artery. It is typically associated with symptoms such as left flank pain, hematuria, proteinuria, and pelvic congestion. The current treatment approach may be conservative in the presence of tolerable symptoms, and surgical or hybrid and stenting procedures in the order of priority in the presence of intolerable symptoms. The aim of this study is to review our experiences to evaluate the results of both methods in this series in which we have a greater tendency toward surgery instead of stenting. METHODS: The clinical data of consecutive patients with nutcracker syndrome who underwent LRV transposition and LRV stenting between July 2019 and October 2023 were retrospectively reviewed. The patients were divided into 2 groups based on the methods of treatment: surgical and stenting. For procedure selection, LRV transposition was primarily recommended, with stenting offered to those who declined. Primary end points were morbidity and mortality. Secondary end points included late complications, patency, freedom from reintervention, and resolution of symptoms. Standard basic statistics and survival analysis methods were employed. RESULTS: Nineteen patients with nutcracker syndrome (female: 100%) were treated with LRV stentings (n = 5) and LRV transposition (n = 14). The mean age was 24 (20-27, interquartile range [IQR]) years. The mean follow-up was 23 (9-32, IQR) months. There were no major complications and mortality after both procedures. The most frequent sign and symptom associated with LRV entrapment were left flank pain 100% (n = 19), proteinuria 88% (n = 15), and hematuria 47% (n = 9). The mean peak velocity ratio on Doppler ultrasound was 6.13 (6-6.44, IQR). Aortomesenteric angle, beak angle (beak sign), and mean diameter ratio on computed tomography were 26° (22.6-28.5, IQR), 25° (23.9-28, IQR), and 5.3 (5-6, IQR), respectively. Venous pressure measurements were only used to confirm the diagnosis in 5 patients in the stenting group. The measured renocaval gradient was 4 (3.9-4.4, IQR) mm Hg. After both procedures, the classical symptoms, including left flank pain, proteinuria, and hematuria, resolved in 89.5% (n = 17), 57.8% (n = 11), and 82.3% (n = 15) of the cases, respectively. A total of 4 patients required reintervention, 3 patients after LRV transposition (occlusion, n = 2; stenosis, n = 1), and 1 patient after stenting (occlusion, n = 1). The 1-year and 3-year primary patency for the 19 patients was 87% and 80%, respectively. Three-year primary-assisted patency was 100%. Similarly, the 1-year and 3-year freedom from reintervention rate was 83% and 72%, respectively. Additionally, the 1-year and 3-year primary patency for the surgical group was 91% and 81%, respectively, and the 1-year and 3-year primary patency for the stenting group was 75%. CONCLUSIONS: Nutcracker syndrome should be kept in mind in cases where flank pain and hematuria cannot be associated with kidney diseases. Radiographic evidence must be accompanied by serious symptoms to initiate the treatment of nutcracker syndrome with LRV transposition and endovascular stenting procedures. Both procedures, along with their respective advantages and disadvantages, can be preferred as primary treatments for nutcracker syndrome. Our study demonstrates that both procedures can be safely and effectively performed, yielding good outcomes.

Reverse-U Aortotomy (Kirali Incision) for Aortic Valvular Interventions.

BACKGROUND: Surgical incisional approach to the ascending aorta is the main strategic step during valvular and/or subvalvular aortic interventions. Classic aortotomy incisions (transverse or oblique) can be challenging and can cause suboptimal exposure of the aortic root especially for the patients with small aortic annulus or for redo coronary artery bypass patients with patent proximal grafts interposed to the ascending aorta. METHODS: The Kirali incision was used in 91 patients (including 13 reoperations) who underwent an aortic intervention for valvular and subvalvular pathologies. Aortic root was exposed by forming inverted "U" shape incision starting from approximately 3 cm above the right coronary ostium toward the center of the noncoronary annulus and the top of the left-right commissure like a tongue. RESULTS: The aortic valve was replaced with a mechanical prosthesis in 45 patients and with a bioprosthesis in 39 patients including 14 sutureless and 16 stentless prostheses. A total of 29 patients received a concomitant procedure per the following: coronary artery bypass grafting on 8 patients and left ventricular assist device on 7 patients. There was no any problem related to aortotomy incision technique such as bleeding, rupture, dehiscence, or laceration perioperatively. There was no complication related to the procedure during 5-year follow-up. CONCLUSION: This new aortotomy incision technique is a safe procedure that provides good exposure for all kinds of aortic valve interventions and protects grafts and can facilitate aortic root enlargement or aortoplasty easily. This incision has the potential to be an alternative to traditional techniques.

Long-Term Results of Thoracofemoral Bypass in the Initial Treatment of Juxtarenal Total Aortic Occlusion.

BACKGROUND: Thoracofemoral bypass has been applied mostly secondary to previous procedures in the treatment of aortoiliac occlusive disease. However, its application as an initial treatment is less common, and long-term outcomes remain uncertain. The aim of this analysis was to review the 16-year experience and long-term outcomes of 31 consecutive patients who underwent thoracofemoral bypass as the primary procedure. METHODS: All patients who underwent thoracofemoral bypass for severe aortoiliac occlusive disease between 2005 and 2021 were retrospectively analyzed. The occlusion and calcified plaques of the abdominal aorta at the renal level were common characteristics of all patients. The patients were divided into 2 groups: severe claudication group (Rutherford III group) and chronic limb-threatening ischemia group (Rutherford IV-V). Chi-square test or Fisher's exact test was used to compare categorical variables between the groups, and t-test or Mann-Whitney U-tests were used to compare continuous variables according to their distributions. The Kaplan-Meier curve was used to depict the time-to-event data. RESULTS: Thirty-one patients [age: 62 (56-67.5); male: 87%] underwent thoracofemoral bypass. Among the 31 patients, 21 (67.7%) belonged to the severe claudication group (Rutherford III), while 10 (32.3%) were in the chronic limb-threatening ischemia (Rutherford IV-V). Twenty-two patients (83.8%) remained asymptomatic after thoracofemoral bypass. The mean follow-up duration was 79 ± 32 months. The 30-day mortality rate was 3.2% (n = 1). Major complications were observed in 9.6% of patients (n = 3; respiratory: 6.4%, retroperitoneal hematoma: 3.2%). No significant difference was found between the claudication and chronic limb-threatening ischemia groups regarding major complications (3.2% vs. 6.4%, P = NS). Minor complications occurred in 41.9% of patients, including pleural effusion 9.6% (n = 3), acute kidney injury 9.6% (n = 3), gastrointestinal bleeding 3.2% (n = 1), paralytic ileus 6.4% (n = 2), and superficial skin infection 12.9% (n = 4). The rate of postoperative superficial skin infection was higher in the chronic limb-threatening ischemia group compared to the claudication group (4 [40%] vs. 0 [0%], P: 0.007). The univariable Cox regression analysis revealed that hypertension and diabetes mellitus were not related to primary patency of the thoracofemoral bypass graft. The 5-year Kaplan-Meier estimated primary patency for the entire study was 96% ± 7% (95% confidence interval [CI]: 88.6-100), and the secondary patency was 96.3% ± 6% (95% CI: 89.4-100). The 5-year Kaplan-Meier estimated survival rate after thoracofemoral bypass was 93.4% ± 3 (95% CI: 91-100). CONCLUSIONS: We demonstrated in this study that thoracofemoral bypass can yield good outcomes when preferred as the initial treatment in selected patients with juxtarenal total aortic occlusion. Despite being a complex surgical technique, thoracofemoral bypass has shown to have safe, acceptable mortality and morbidity rates, as well as excellent long-term follow-up results in selected patients.

Transcatheter Closure or Surgery for Symptomatic Paravalvular Leaks: The Multicenter KISS Registry.

BACKGROUND: The optimal treatment of symptomatic paravalvular leak (PVL) remains controversial between transcatheter closure (TC) and surgery. This large-scale study aimed to retrospectively evaluate the long-term outcomes of the patients who underwent reoperation or TC of PVLs. METHODS AND RESULTS: A total of 335 (men, 209 [62.4%]; mean age, 58.15±12.77 years) patients who underwent treatment of PVL at 3 tertiary centers between January 2002 and December 2021 were included. Echocardiographic features, procedure details, and in-hospital or long-term outcomes were assessed. The primary end point was defined as the all-cause death during follow-up. The regression models were adjusted by applying the inverse probability weighted approach to reduce treatment selection bias. The initial management strategy was TC in 171 (51%) patients and surgery in 164 (49%) cases. Three hundred cases (89.6%) had mitral PVL, and 35 (10.4%) had aortic PVL. The mean left ventricular ejection fraction was 52.03±10.79%. Technical (78.9 versus 76.2%; P=0.549) and procedural success (73.7 versus 65.2%; P=0.093) were similar between both groups. In both univariate and multivariable logistic regression analysis, the in-hospital mortality rate in the overall population was significantly higher (15.9 versus 4.7%) in the surgery group compared with the TC group (unadjusted odds ratio, 3.13 [95% CI, 1.75-5.88]; P=0.001; and adjusted odds ratio (inverse probability-weighted), 4.55 [95% CI, 2.27-10.0]; P<0.001). However, the long-term mortality rate in the overall population did not differ between the surgery group and the TC group (unadjusted hazard ratio [HR], 0.86 [95% CI, 0.59-1.25]; P=0.435; and adjusted HR (inverse probability-weighted), 1.11 [95% CI, 0.67-1.81]; P=0.679). CONCLUSIONS: The current data suggest that percutaneous closure of PVL was associated with lower early and comparable long-term mortality rates compared with surgery.

Cardiovascular surgery during the first wave of COVID-19 pandemic.

Background: In this study, we aimed to evaluate primary outcomes and main characteristics of emergency and elective/urgent cardiovascular surgeries which were performed in the first three months of the novel coronavirus disease 2019 (COVID-19) pandemic in our center. Methods: Between March 11th, 2020 and June 11th, 2020, a total of 209 patients (44 males, 165 females; mean age: 57.3±12.8 years; range, 20 to 80 years) who underwent emergency or elective/urgent surgery with cardiovascular pathologies were retrospectively analyzed. The patients were classified as emergency and elective/urgent according to the level of necessity of the surgical procedure at the time of hospital admission. Pre-, intra-, and postoperative data of the patients were recorded. Results: During the study period, 156 elective/urgent and 74 emergency cardiovascular surgeries were performed. Six COVID-19 (+) patients were operated emergently. The number of acute aortic dissection and peripheral vascular surgery was higher in the emergency group (p<0.05). Two patients who were COVID-19 (-) preoperatively became COVID-19 (+) in the postoperative period. In these patients, acute respiratory distress syndrome developed, and extracorporeal membrane oxygenation support was needed. Four patients who needed post-cardiotomy extracorporeal membrane oxygenation support due to low cardiac output were COVID-19 (-) both in the pre- and postoperative periods. The overall in-hospital mortality rate was 9.1%. Conclusion: Even during pandemic such as COVID-19, referral centers with experienced personnel can provide non-pandemic healthcare with a quality close to the daily routine.

Evaluation of donor-derived bacterial infections in lung transplant recipients.

Background: This study aims to evaluate the etiology and outcomes of donor-derived bacterial infections in patients undergoing lung transplantation. Methods: Between January 2013 and December 2017, a total of 71 lung transplant recipients (56 males, 15 females; median age: 43.3 years) were retrospectively analyzed. The diagnosis of donor-derived bacterial infection was defined as the isolation of the same bacteria with the same antibiotic susceptibility patterns in a lung sample of donor and in one sample obtained from patients after transplantation and the presence of clinical evidence of infection. Results: Ten (14%) patients were found to have donor-derived bacterial infection. Acinetobacter baumannii was found in three, Pseudomonas aeruginosa in three, Klebsiella pneumoniae in one, Enterobacter cloacae in one, Staphylococcus aureus in one, and both Klebsiella pneumoniae and Acinetobacter baumannii in one patient. Twenty-four of lung-transplant recipients and four patients with donor-derived infection died. Conclusion: Lung transplants are usually performed in hospitalized patients or in those admitted to the intensive care unit. These patients commonly experience infection and colonization with resistant microorganisms.

Cost-Effectiveness and Clinical Outcome of Transcatheter Versus Sutureless Aortic Valve Replacement.

BACKGROUND: Sutureless aortic valve replacement (SU-AVR) and transcatheter aortic valve implantation (TAVI) are becoming increasingly common. The aim of this study is to compare the clinical outcome and cost-effectiveness of the two methods. METHODS: In this study, cross-sectional retrospective data were collected on 327 patients who underwent SU-AVR (n = 168) and TAVI (n = 159). Homogeneous groups were provided by the "propensity score matching" method, and 61 patients from the SU-AVR group and 53 patients from the TAVI group were included in the study sample. RESULTS: The two groups did not have statistically different death rates, complications after surgery, lengths of hospital stays, or visits to the intensive care unit. It is stated that the SU-AVR method provides an additional 1.14 Quality-Adjusted Life Year (QALY) compared to the TAVI method. The TAVI was more expensive than the SU-AVR in our study, but the difference was not statistically significant ($40,520.62 vs. $38,405.62, p > 0.05). For SU-AVR, the most expensive factor was the length of stay in the intensive care unit; for TAVI, it was arrhythmia, bleeding, and renal failure. CONCLUSIONS: These bioprostheses are safe and effective treatments for valve stenosis. Clinical outcomes were similar between the two groups. Therefore, clinicians may find it difficult to determine an effective treatment strategy. According to the evaluation made in terms of cost-effectiveness, it was found that the SU-AVR method gave a higher QALY at a lower cost compared to the TAVI method. However, this result is not statistically significant.

Long-term experience of the modified David V re-implantation technique for valve-sparing aortic root replacement.

OBJECTIVE: The modified David V technique is one of the valve-sparing aortic root replacement (V-SARR) techniques, which is an alternative to traditional composite valve graft root replacement techniques. We aimed to analyse our long-term experience with the modified David V re-implantation technique for the treatment of aortic root aneurysm and significant aortic valve insufficiency. METHODS: From March 2009 to November 2021 the modified David V re-implantation technique, one of the V-SARR techniques, was performed on 48 patients in our centre. The results were analysed retrospectively. Two different-sized grafts were used in all patients. The grafts used in the proximal position were larger than the distal grafts. We performed both intra-operative and post-procedural transoesophageal echocardiography on each patient. All patients were followed by means of transthoracic echocardiography. The mean follow-up period was 5.7 ± 3.1 years. RESULTS: The mean age of this cohort was 56.3 ± 14.3 years (24-79) and the majority were men (75%). The mean aortic root diameter was 5.1 ± 0.6 cm. The mean diameter for the assending aorta was 5.4 ± 2.1 cm. The in-hospital mortality rate was 4.2% (n = 2). One patient needed aortic valve replacement in the early postoperative period. Two (4.2%) patients died in the early postoperative period and four (8.3%) died in the late postoperative period. Overall survival was 91 ± 4 and 86 ± 5% at one and five years, respectively. Aortic valve insufficiency was at moderate levels postoperatively. Freedom from moderate to severe residual aortic insufficiency was 89.6% at 10 years. None of the patients needed late re-operation of the aortic valve postoperatively. Freedom from valve re-operation was 100% at the end of the follow up. CONCLUSION: Our study shows that the David V technique is associated with excellent long-term durability, a remarkably low rate of valve-related complications, and it protects the re-implanted native aortic valve from a second operation. Additionally this technique could be safely implemented in patients with a bicuspid aortic valve and acute type A aortic dissection without leaflet deformity.

In-hospital and 6-month outcomes in patients with COVID-19 supported with extracorporeal membrane oxygenation (EuroECMO-COVID): a multicentre, prospective observational study.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has been widely used in patients with COVID-19, but uncertainty remains about the determinants of in-hospital mortality and data on post-discharge outcomes are scarce. The aims of this study were to investigate the variables associated with in-hospital outcomes in patients who received ECMO during the first wave of COVID-19 and to describe the status of patients 6 months after ECMO initiation. METHODS: EuroECMO-COVID is a prospective, multicentre, observational study developed by the European Extracorporeal Life Support Organization. This study was based on data from patients aged 16 years or older who received ECMO support for refractory COVID-19 during the first wave of the pandemic-from March 1 to Sept 13, 2020-at 133 centres in 21 countries. In-hospital mortality and mortality 6 months after ECMO initiation were the primary outcomes. Mixed-Cox proportional hazards models were used to investigate associations between patient and management-related variables (eg, patient demographics, comorbidities, pre-ECMO status, and ECMO characteristics and complications) and in-hospital deaths. Survival status at 6 months was established through patient contact or institutional charts review. This study is registered with ClinicalTrials.gov, NCT04366921, and is ongoing. FINDINGS: Between March 1 and Sept 13, 2020, 1215 patients (942 [78%] men and 267 [22%] women; median age 53 years [IQR 46-60]) were included in the study. Median ECMO duration was 15 days (IQR 8-27). 602 (50%) of 1215 patients died in hospital, and 852 (74%) patients had at least one complication. Multiorgan failure was the leading cause of death (192 [36%] of 528 patients who died with available data). In mixed-Cox analyses, age of 60 years or older, use of inotropes and vasopressors before ECMO initiation, chronic renal failure, and time from intubation to ECMO initiation of 4 days or more were associated with higher in-hospital mortality. 613 patients did not die in hospital, and 547 (95%) of 577 patients for whom data were available were alive at 6 months. 102 (24%) of 431 patients had returned to full-time work at 6 months, and 57 (13%) of 428 patients had returned to part-time work. At 6 months, respiratory rehabilitation was required in 88 (17%) of 522 patients with available data, and the most common residual symptoms included dyspnoea (185 [35%] of 523 patients) and cardiac (52 [10%] of 514 patients) or neurocognitive (66 [13%] of 512 patients) symptoms. INTERPRETATION: Patient's age, timing of cannulation (<4 days vs ≥4 days from intubation), and use of inotropes and vasopressors are essential factors to consider when analysing the outcomes of patients receiving ECMO for COVID-19. Despite post-discharge survival being favourable, persisting long-term symptoms suggest that dedicated post-ECMO follow-up programmes are required. FUNDING: None.

Comparison of sequential organ failure assessment score and cardiac surgery score systems for mortality prediction after emergency acute aortic dissection surgery.

BACKGROUND: Acute type A aortic dissection (ATAAD) is one of the most mortal cardiovascular diseases and requires urgent diagnosis and surgery. The patient's clinical findings, complications, and patient's history are closely related to mortality rates. Cardiac surgery score (CASUS) is a scoring system which is calculated by considering the special pathophysiological conditions of patients undergoing cardiac surgery and predicts post-operative results with high accuracy. METHODS: Following the ethical approval from institutional ethics committee (ID: 2021/7/496), the data of consecutive 50 ATAAD patients who underwent emergent surgery in our hospital between January 1, 2019, and December 31, 2020, were evaluated. The Sequential Organ Failure Assessment and CASUS scores were calculated using the worst values of the daily laboratory and neurological status for both in admission to emergency department and during intensive care unit (ICU) follow-up period. The average and the total values of these scores were recorded for pre-operative, post-operative 1st day, and for the categorical data were defined as frequency and percentage. We used the Mann-Whitney U test for the independent continuous data comparisons and Pearson Chi-Square or Fisher exact test for categorical data comparison whole ICU period. Continuous data were presented as median and interquartile ranges (25-75th). RESULTS: The study comprised 50 patients, the rate of death was 34% (n=17). In total group, there were hypertension 72% (n=36), diabetes mellitus 24% (n=12), initial hemoglobin 12.5 g/dL (10.7-14.1, 25-75th), creatinine 1.09 mg/dL (0.85-1.33, 25-75th), and 72% (n=36) of these patients were male. The CASUSmean and SOFAmean scores were higher in the death-group when compared with the group who survived (12.9 [9.5-13.8, 25-75th], 3 [2-5, 25-75th]; 8 [6.1-9.2, 25-75th], 2.6 (2-4.5, 25-75th], p<0.001, respectively]. CASUSmean was independently associated with the 1-month mortality in model 1 (HR 1.25 [1.14-1.37] (p<0.001). CONCLUSION: According to our results increase in CASUS mean was the main predictor of 1 month mortality. When CASUS mean exceeds 8.3 the patient should be followed up more carefully for major adverse events including death.

Serum Levels of Cholesterol and Lipoproteins in Patients With Symptomatic Paravalvular Leaks.

Paravalvular leak (PVL) is a complication of valve replacement surgery which may lead to serious clinical consequences including hemolytic anemia. This study aimed to retrospectively evaluate the effect of successful intervention on serum lipid parameters in patients with PVL. A total of 106 patients (mean age: 57.2 ± 13.6 years, male: 67) who underwent surgical or transcatheter closure for symptomatic PVL were enrolled in this study. During the follow-up period, hemolysis and lipid parameters were evaluated at each clinical visit. This is the first study describing the effects of PVL on lipid metabolism after surgical or transcatheter closure. In the study, 18 patients (17%) had aortic PVL, 84 patients (79%) had mitral PVL, and 4 patients (3.8%) had both aortic and mitral PVL. A total of 59 patients underwent transcatheter closure and 47 patients were treated surgically. Technical success of the procedures was 83%. After successful PVL closure, hemoglobin and haptoglobin levels increased significantly (9.5 ± 1.3 vs 11.9 ± 2.1 g/dl, p <0.001 and 16.6 ± 7.9 vs 34.1 ± 19.9 mg, p <0.001, respectively). A significant increase in total cholesterol (158.9 ± 42.7 vs 209.3 ± 58.7 mg/dl, p <0.001), low-density lipoprotein cholesterol (99.1 ± 33.8 vs 133.9 ± 45.7 mg/dl, p <0.001), and high-density lipoprotein cholesterol (39.8 ± 12.4 vs 44.8 ± 11.7 mg/dl, p <0.001) levels was observed after successful PVL closure. In conclusion, symptomatic patients with PVL had hypocholesterolemia, reflected by low serum lipoprotein levels. After successful PVL closure, an increase in serum lipoprotein levels was observed. The recovery in levels of lipoproteins could be used as a marker of successful PVL closure, and absence of recovery of lipoprotein levels may indicate incomplete closure.

COVID-19 ARDS in two patients with left ventricular assist device.

Coronavirus disease 2019 affected millions of people and caused pneumonia, acute respiratory distress syndrome and increased mortality worldwide. Data from multicenter studies showed that concomitant chronic diseases are associated with severe coronavirus disease. Patients with left ventricular assist device (LVAD) support may also be vulnerable to the disease. Some symptoms of COVID-19 infection like dyspnea and fatigue can overlap with heart failure or LVAD dysfunction. Careful evaluation should be made to diagnose and treat these patients. In these two cases with COVID-19, here we presented the first two patients supported with LVAD in Turkey.

Risk Factors for Mortality in Patients with Stenotrophomonas maltophilia Bloodstream Infections in Immunocompetent Patients.

Objective: This study aimed to evaluate bloodstream infections caused by Stenotrophomonas maltophilia in immunocompetent patients with respect to clinical features and risk factors for mortality. Methods: We reviewed bloodstream infections detected between January 1, 2012, and July 1, 2021, to identify nosocomial S. maltophilia bacteremia in Kosuyolu Research and Training Hospital. Results: We identified a total of 97 patients with S. maltophilia bloodstream infections. Of these, 17 patients were excluded because of community-acquired infections (n=9), contamination with S. maltophilia (n=3), and insufficient data (n=5), with 80 (57.5% males) patients remaining for analysis. The source of infection was the respiratory tract in 28 (35%) patients. A central venous catheter was used in 60 (75%) patients, which required replacement in 23 patients within five days after detecting S. maltophilia bacteremia. On antimicrobial susceptibility testing, 71 strains were found to be susceptible and 9 (11.3%) resistant to trimethoprim-sulfamethoxazole. Thirty-day mortality was 33.8%. Non-survivors differed significantly from survivors with respect to higher rates of central venous catheters ( p=0.020), mechanical ventilation (p=0.006), urinary catheters (p=0.021), septic shock (p=0.001), hypoalbuminemia (p=0.026) and thrombocytopenia (p =0.039). S. maltophilia bacteremia was independently associated with mortality in patients with hypoalbuminemia, and replacement of central venous catheters had a protective role in reducing mortality. Conclusion: As with other bacterial infections, S. maltophilia bacteremia is associated with a considerably high mortality rate in patients with cardiac conditions. The replacement of the catheter seems to play a beneficial role in 30-day survival.

Thyroid Dysfunction among the Patients with Critical COVID-19.

Objective: Since the angiotensin-converting enzyme (ACE) is the functional receptor for SARS-CoV-2, predominantly expressed by the alveoli, SARS-CoV-2 primarily involves the lungs. Aside from the lungs, ACE is expressed in other organs, including the thyroid gland. This study aimed to evaluate the incidence of thyroid dysfunction (TD) in patients admitted to the intensive care unit (ICU) with critical COVID-19, with inflammatory markers and disease severity, compared to patients with normal thyroid function. Materials and Methods: This retrospective study included 52 patients admitted to the ICU with PCR-confirmed critical COVID-19 between April 2020 and September 2021.Thyroid function tests were obtained within the first three days after ICU admission. TD was defined as the detection of any abnormal level in thyroid-stimulating hormone (TSH), free thyroxine hormone (FT4), and free triiodothyronine hormone (FT3).None of the patients had a prior history of thyroid disease or received medications related to thyroid diseases. Results: TD was detected in 34 patients (65.4%). The majority of patients (67%) required extracorporeal membrane oxygenation (ECMO), with a higher frequency in patients with TD (74%). Patients with and without TD were similar concerning age, gender, and the need for ECMO. Patients with TD had significantly decreased levels of TSH, FT3, and FT4 (p=0.002, <0.001, =0.005, respectively); a significantly greater acute physiology and chronic health evaluation II (APACHE-II) score (p=0.048); a significantly higher white blood cell count (p=0.031) and elevated levels of procalcitonin (p=0.003), C-reactive protein (p=0.049) and cardiac troponin T (p=0.025). Other parameters, such as ICU stay, sequential organ failure assessment [SOFA] score, and mortality, did not differ significantly (p=0.449, p=0.315, p=0.142, respectively). Conclusion: Our findings suggest that patients admitted to the ICU with critical COVID-19 are at an increased risk for the development of TD, which should also be taken into account in relation to inflammatory markers, cardiac troponin T levels, and APACHE-II scores.

Extracorporeal cardiopulmonary resuscitation in-hospital cardiac arrest due to acute coronary syndrome.

BACKGROUND: The aim of this study was to analyze the effect of extracorporeal cardiopulmonary resuscitation on survival and neurological outcomes in in-hospital cardiac arrest patients. METHODS: Between January 2018 and December 2020, a total of 22 patients (17 males, 5 females; mean age: 52.8±9.0 years; range, 32 to 70 years) treated with extracorporeal cardiopulmonary resuscitation using veno-arterial extracorporeal membrane oxygenation support for in-hospital cardiac arrest after acute coronary syndrome were retrospectively analyzed. The patients were divided into two groups as those weaned (n=13) and non-weaned (n=9) from the veno-arterial extracorporeal membrane oxygenation. Demographic data of the patients, heart rhythms at the beginning of conventional cardiopulmonary resuscitation, the angiographic and interventional results, survival and neurological outcomes of the patients before and after extracorporeal cardiopulmonary resuscitation were recorded. RESULTS: There was no significant difference between the groups in terms of comorbidity and baseline laboratory test values. The underlying rhythm was ventricular fibrillation in 92% of the patients in the weaned group and there was no cardiac rhythm in 67% of the patients in the non-weaned group (p=0.125). The recovery in the mean left ventricular ejection fraction was significantly evident in the weaned group (36.5±12.7% vs. 21.1±7.4%, respectively; p=0.004). The overall wean rate from veno-arterial extracorporeal membrane oxygenation was 59.1%; however, the discharge rate from hospital of survivors without any neurological sequelae was 36.4%. CONCLUSION: In-hospital cardiac arrest is a critical emergency situation requiring instantly life-saving interventions through conventional cardiopulmonary resuscitation. If it fails, extracorporeal cardiopulmonary resuscitation should be initiated, regardless the underlying etiology or rhythm disturbances. An effective conventional cardiopulmonary resuscitation is mandatory to prevent brain and body hypoperfusion.

The cost of one unit blood transfusion components and cost-effectiveness analysis results of transfusion improvement program.

BACKGROUND: This study aims to analyze the cost of the entire transfusion process in Turkey including evaluation of the cost of transfusion from the perspective of hospital management and determination of savings achieved with the transfusion improvement program. METHODS: Invoices, labor, material costs were calculated with micro-costing method, while general production expenses were calculated with gross costing method between January 2018 and December 2019. Unit costs for each blood product were calculated separately by collecting unit acquisition costs, material costs, labor costs, and general production expenses and, then, distributed into six different blood products as follows: erythrocyte suspension, fresh frozen plasma, pooled platelet, apheresis platelet, cryoprecipitate, fresh whole blood. The total costs for 2018 and 2019 were calculated and the savings achieved were estimated. The Turkish Lira was converted into the United States Dollar ($) currency using the purchasing power parity. RESULTS: In 2018/2019, the blood component transfusion cost was $240.90/251.18 for erythrocyte suspension, $120.00/128.67 for fresh frozen plasma, $313.50/322.19 for pooled platelet, $314.24/325.73 for apheresis platelet, $104.95/113.99 for cryoprecipitate, and $189.91/209.09 for fresh whole blood. The total transfusion cost was $6,224,208.33 in 2108 and $5,308,148.43 in 2019. As a result of the transfusion improvement program launched in 2019, the amount of blood components decreased by 23.24%, compared to the previous year, and a saving of $916,059.9 was achieved. CONCLUSION: The transfusion is a burden for both the hospital management systems and the country's economy. To accurately calculate and manage this economic burden is important for sustainable healthcare services.

Follow-up strategy with long-term veno-venous extracorporeal membrane oxygenation support for complicated severe acute respiratory distress related to COVID-19 and recovery of the lungs.

Novel coronavirus-2019 (COVID-19) pandemic has affected all over the world, leading to viral pneumonia-complicating severe acute respiratory distress syndrome and death. Although there is no proven definitive treatment yet, physicians use some assistive methods based on the previous epidemic viral acute respiratory distress syndrome experiences. Extracorporeal membrane oxygenation is one of them. In this report, we present one of the longest survived extracorporeal membrane oxygenation case (71 days) with COVID-19 infection and the pathology of the infected lung, with our veno-venous extracorporeal membrane oxygenation strategy.

MitraClip Removal During Left Ventricular Assist Device Implantation.

Mitral regurgitation (MR) is an important consequence of heart failure (HF) patients, which increases hospitalization and mortality rates. The MitraClip procedure is increasingly preferred for HF patients with obvious MR to improve MR and related symptoms. In some cases, patients may need further intervention such as left ventricular assist device implantation with the aim of improving progressive clinical deterioration caused by the progression of HF or mitral clip associated complications (i.e., detachment or mitral stenosis). This case study summarizes our two patients who received concomitant mitral clip removal and left ventricular assist device implantation with clinically successful results.