Valve sparing surgery in an adult patient with dextrocardia and annuloaortic ectasia.

We report the case of a patient with situs inversus totalis, annuloaortic ectasia complicated by aortic insufficiency and mitral regurgitation which induced congestive heart failure. Both valvular lesions were repaired physiologically using aortic root sparing Yacoub 'remodeling' technique and mitral ring annuloplasty. Valve sparing techniques can be used effectively even in patients with complicated clinical scenarios (like dextrocardia and annuloaortic ectasia) to avoid the potential risks related to prosthetic valve implantation and lifelong anticoagulation therapy.

Altered expression of micro-RNA 199a and increased levels of cardiac SIRT1 protein are associated with the occurrence of atrial fibrillation after coronary artery bypass graft surgery.

BACKGROUND: Postoperative atrial fibrillation (POAF) is a potentially life-threatening complication after coronary artery bypass graft (CABG) surgery. The expression of the cardioprotective SIRT1 protein with its antioxidant activity is increased in cardiac tissue of patients suffering from POAF. So far, information is lacking about the relationship between SIRT1 regulating micro RNAs (miRs), SIRT1 protein and the occurrence of POAF. METHODS: A total of 63 patients undergoing CABG were recruited, and biopsies were obtained from the right atrial appendage during cannulation. Postoperative, all patients were rhythm-monitored until discharge and randomized to POAF (n=20) or sinus rhythm (n=43). The expression of the micro RNAs miR-199a and miR-195 was quantified by real-time PCR. SIRT1 protein was detected by western blot analysis. RESULTS: The relative expression of miR-199a in the POAF group was significantly decreased compared to the control group (0.77±0.27 vs. 1.11±0.69, P=.022) Accordingly, SIRT 1 protein was significantly induced in tissue probes of patients with POAF (P<.001). CONCLUSION: Altered expression of the SIRT1 protein regulating miR-199a in human atrial tissue was found to be related to the occurrence of POAF, indicating its usefulness as a biomarker for cardiac surgery management.

Posterior leaflet segment 2 plication in ischemic mitral regurgitation repair.

AIM: To evaluate the medium-term results of plication of posterior leaflet segment 2 in addition to ring annuloplasty in patients with functional ischemic mitral regurgitation. METHODS: The study included 136 patients who underwent mitral valve repair with plication of posterior leaflet segment 2 for ischemic mitral regurgitation between 2004 and 2012. The direction and correlation of left ventricle sphericity and tethering area were established by Pearson correlation analysis in patients with or without recurrent mitral regurgitation in the medium term. RESULTS: Medium-term survival was 91.9% and freedom from moderate or severe mitral regurgitation was 89.6%. In medium-term follow-up, transthoracic echocardiography found a significant decrease in tethering area, coaptation height, and distance between the commissures compared to the pre-surgery values (p = 0.0001 in all). The distance between the papillary muscles was reduced compared to the pre-surgery period but it was not significant (p = 0.204). Pearson correlation analysis found no significant correlation between the tethering area and left ventricle sphericity in patients without recurrent mitral regurgitation (r = 0.15, p = 0.36), a highly positive correlation (r = 0.44, p < 0.001) in patients with mild recurrent mitral regurgitation, and a moderately positive correlation (r = 0.71, p < 0.01) in patients with moderate or severe recurrent mitral regurgitation. CONCLUSIONS: The tethering area, coaptation height, and distance between the commissures decreased significantly, thus posterior leaflet segment 2 plication in addition to ring annuloplasty may be the optional procedure to ensure freedom from moderate or severe mitral regurgitation.

Assessment of carotid body tumor and its association with tetralogy of fallot: effect of the chronic hypoxia.

This is a rare combined presentation of Tetralogy of Fallot and carotid body tumor (CBT). Hypotheses and further discussion provides data for the development of CBT as a response to chronic hypoxemia. This present study demonstrates and discusses such an occurrence.

Single coronary artery anomaly causing ischemic mitral insufficiency.

Single coronary artery anomaly is rarely seen, and although it can present with sudden death, chest pain, arrhythmia, myocardial infarction, or congestive heart failure, it can also be asymptomatic. We describe the case of a 58-year-old man with single coronary artery anomaly in whom the coronary artery stemmed from the left coronary sinus and caused ischemic mitral insufficiency due to left anterior descending artery stenosis. He underwent successful mitral valve repair and coronary bypass.

Ischaemic mitral regurgitation: The effects of ring annuloplasty and suture annuloplasty repair techniques on left ventricular re-remodeling.

OBJECTIVE: To examine the mid-term results of patients on whom a coronary revascularization as well as a mitral ring and suture annuloplasty have been performed due to coronary artery disease (CAD) and ischaemic mitral regurgitation (IMR). METHODOLOGY: Totally 73 patients on whom a revascularization and a mitral valve repair due to CAD and IMR had been performed in our clinic between 2000-2008 were included in the study. Patients were divided into two groups one of which included 38 patients (52.05%) on whom a coronary artery bypass graft (CABG) and a ring annuloplasty on the mitral valve had been performed (Group 1) and the other one 35 patients (47.95%) on whom only suture annuloplasty as well as a CABG had been performed (Group 2). The study was planned retrospectively and study data have been obtained by screening the hospital registries retrospectively. In the mid-term, patients were invited for a check and their intragroup and intergroup echocardiographic parameters and functional capacities were assessed statistically. RESULTS: In pre-operational and post-operational intragroup assessment in terms of echocardiographic findings; although LVEDD, LVESD, EDV, PAP and the degree of recurrent MR have been decreased in both groups, the decrease in LVESD and PAP and the low degree of recurrent MR were statistically significant in Group 1 patients (p=0.047, p=0.023, p=0.01, respectively). When the mid-term intergroup echocardiograpic findings were assessed; PAP and recurrent MR have been determined statistically lower in Group 1 patients (p=0.005, p=0.08, respectively). The length of intensive care unit stay, length of hospitalization and length of detachment from respiratory support were statistically significantly longer in ring annuloplasty performed group (p=0.012, p=0.033, p=0.029, respectively). CONCLUSIONS: In moderate to severe IMR patients, a positive contribution can be provided to ventricular remodeling by a ring annuloplasty through a significant decrease in left ventricular diameter and a low recurrent MR and PAP.

Posterobasal left ventricular aneurysms: surgical treatment and long-term outcomes.

This retrospective study analyzes short- and long-term outcomes in 18 patients who underwent repair of posterobasal left ventricular aneurysm from January 1993 through December 2009. As concomitant procedures, mitral reconstruction was performed in 4 patients, ventricular septal defect repair in 2 patients, and coronary artery bypass grafting in 17 patients. In regard to surgical technique, 10 patients underwent patch repair and 8 underwent closure by linear suture. The in-hospital mortality rate was 11% (2 patients). An intra-aortic balloon pump was placed postoperatively in 1 patient. One patient underwent reoperation for mediastinitis and 2 for bleeding. The 1-, 5-, and 10-year survival rates were 82%, 76%, and 52%, respectively. Posterobasal left ventricular aneurysm repair can be performed with low short-term mortality rates and good long-term outcomes. It must be judged whether a linear repair or patch repair is better, in accordance with aneurysm size and the concomitant operative procedure, if any.

Effects of ischemic preconditioning and iloprost on myocardial ischemia-reperfusion damage in rats.

This study investigates the effects of cardiac ischemic preconditioning and iloprost on reperfusion damage in rats with myocardial ischemia/reperfusion. 38 male Wistar Albino rats used in this study were divided into 5 groups. The control group (Group 1) (n=6), ischemia/reperfusion (IR) group (Group 2) (n=8), cardiac ischemic preconditioning (CIP) group (Group 3) (n=8), iloprost (ILO) group (Group 4) (n=8), and cardiac ischemic preconditioning + iloprost (CIP+ILO) group (Group 5) (n=8). Pre-ischemia, 15 minutes post-ischemia, 45 minutes post-reperfusion, mean blood pressure (MBP), and heart rates (HR) were recorded. The rate-pressure product (RPP) was calculated. Post-reperfusion plasma creatine kinase-MB (CK-MB), lactate dehydrogenase (LDH), troponin (cTn) vlaues, and infarct size/area at risk (IS/AAR) were calculated from myocardial tissue samples. Arrhythmia and ST segment elevations were evaluated during the ischemia and reperfusion stages. Although the MBP, HR, RPP values, biochemical parameters of CK-MB and LDH levels, IS/AAR rates, ST segment elevation values were found to be similar in CIP and CIP+ILO groups and the IR and ILO groups (p>0.05), CIP-containing group values had a positively meaningful difference (p<0.05) compared with the IR and ILO group. While mild-moderate findings of damage were observed in Group 3 and Group 5, severely findings of damage were releaved in Group 2 and Group 4. The arrhythmia score of the ILO group was meaningfully lower (F: 41.4, p<0.001) than the IR group. We can conclude that the effects of myocardial reperfusion damage can be reduced by cardiac ischemic preconditioning, intravenous iloprost reduced the incidence of ventricular arrhythmia associated with reperfusion, and its use with CIP caused no additional changes.

Comparison of the health related quality of life of patients following mitral valve surgical procedures in the 6-months follow-up: a prospective study.

PURPOSE: The aim of the present study is to evaluate the health-related quality of life of the patients who underwent mitral valve repair (MvRp) and mitral valve replacement (MVR). METHODS: Within the scope of this prospective study design, 56 patients who had mitral valve operation between the years of 2011-2012 were enrolled in the study. 24 (42.8%) of these patients had MVR while 32 (57.1%) of them had MvRp. The health-related quality of life was evaluated according to the Turkey norms of Short Form 36 Quality-Of-Life Measures (SF-36), which were filled in by the patients before and 6 months after the operation. Moreover, preoperative risk factors affecting the quality of life (age, gender, functional capacity, rhythm, hypertension, diabetes, applied surgical method and echocardiographic results) were investigated for all the patients (n = 56) by using independent sample t test analysis. RESULTS: When the pre and postoperative changes were compared between the two groups, it was found out that there were no significant difference between the groups in terms of restraints on physical role functioning (PR), and the social role functioning values (SF) (respectively; p = 0.097, p = 0.105). However, in the comparison of pre-/postoperative changes between the groups, the changes in physical functioning (PF), bodily pain (BP), general health (GH), vitality (VT) and restraints on emotional role functioning (RE) and mental health (MH) values were found out to be significantly superior in the MvRp group than in the MVR group (respectively; p <0.01, p <0.05, p <0.01, p <0.01, p <0.05 and p <0.01). It was also confirmed that female gender, atrial fibrillation (AFR), and MVR method negatively affected the physical and mental components (respectively; p = 0.033, p = 0.003, p = 0.015). CONCLUSION: RESULTS of the SF-36 quality of life measures show that quality of life may be better in patients that have had MvRp. It should be considered that the planned surgical treatment method can affect the patient's quality of life, and this effect can indicate the success of the surgical treatment.

A rare complication of pre-Eisenmenger patent ductus arteriosus: Pulmonary artery dissection.

INTRODUCTION: Pulmonary artery dissection associated with patent ductus arteriosus is usually seen in patients with pulmonary hypertension and Eisenmenger's syndrome. This paper presents a case with pre-Eisenmenger patent ductus arteriosus complicated by pulmonary artery dissection, and explains how she was surgically treated. PRESENTATION OF CASE: The transthoracic echocardiography of a 21-year-old woman complaining of effort dyspnea revealed patent ductus arteriosus. Contrast-enhanced thoracic computed tomography scan showed patent ductus arteriosus and dissection in the main pulmonary artery extending from the edge of the patent ductus arteriosus orifice to the pulmonary valve. The patent ductus arteriosus was divided with pledgeted prolene suture and the dissected aneurysmal portion of the pulmonary artery was resected by surgery. Dacron graft interposition was applied to the main pulmonary artery. DISCUSSION: Because rupture causes cardiogenic shock and sudden death, diagnosis is rare in the living subject and pulmonary artery dissection is frequently detected in autopsy. A case with pulmonary artery dissection as a result of patent ductus arteriosus has been reported in the literature, but the patient died in the preoperative period. In our study, the patient was not diagnosed to have Eisenmenger's syndrome, but had pulmonary artery dissection, a complication arising from patent ductus arteriosus. The patient underwent curative surgery that included pulmonary artery dissection repair and closure of the patent ductus arteriosus. CONCLUSION: In addition to pulmonary artery aneurysm, pulmonary artery dissection must also be considered as a complication in cases of patent ductus arteriosus with high pulmonary artery pressure diagnosed in adulthood.

Prognostic significance of the absence of normal septal Q waves before aortic valve replacement.

PURPOSE: Aim of this study was to investigate the prognostic significance of absence of septal Q waves in patients scheduled for aortic valve replacement. MATERIAL AND METHODS: Sixty-one patients who underwent isolated aortic valve replacement for aortic stenosis were retrospectively evaluated. Septal Q waves were defined as Q waves of<2mm in amplitude and<40ms in width and absence of septal Q waves was defined as simultaneous loss of Q waves from at least three of the leads I, aVL, V5 and V6. Septal Q waves were absent in 17 patients (Group AQ, 27.8%) and were present in 44 patients (Group PQ, 72.1 %) preoperatively. Newly developed AV block>1st degree and newly developed left bundle branch block were primary endpoints. RESULTS: Preoperatively, absence of normal septal Q waves was significantly associated with increased risk of postoperative AV block (HR: 11.18, range 1.37-91.21, 95% CI, p=0.02) whereas it was not associated with increased risk for newly developed LBBB (HR: 3.15 0.62-15.83, 95% CI, p=0.16). CONCLUSION: Absence of normal septal Q waves in the preoperative ECG may predict further delay in conduction which might develop in the early postoperative course of aortic valve replacement.

Red cell distribution width predicts new-onset atrial fibrillation after coronary artery bypass grafting.

INTRODUCTION: Red cell distribution width (RDW) has been associated with poor outcomes in patients with cardiovascular diseases. However, little is known about the role of RDW in prediction of new-onset atrial fibrillation (AF) after coronary artery bypass grafting (CABG). We aimed to investigate the relation between the RDW and postoperative AF in patients undergoing CABG. METHODS: A total of 132 patients undergoing nonemergency CABG were included in the study. Patients with previous atrial arrhythmia or requiring concomitant valve surgery were excluded. We retrospectively analyzed 132 consecutive patients (mean age, 60.55 ± 9.5 years; 99 male and 33 female). The RDW level was determined preoperatively and on postoperative Day 1. RESULTS: Preoperative RDW levels were significantly higher in patients who developed AF than in those who did not (13.9 ± 1.4 vs. 13.3 ± 1.2, p = 0.03). There was not any correlation between postoperative RDW levels and AF. Using a cutpoint of 13.45, the preoperative level correlated with the incidence of AF with a sensitivity of 61% and specificity of 60%. CONCLUSION: Preoperative RDW level predicts new-onset AF after CABG in patients without histories of AF.

Successful emergency double valve repair operation during acute aortic dissection type A.

Reconstructive valve surgery in acute aortic dissection type A (AADTA) remains challenging. We describe a case of successful combined repair of the aortic and mitral valves, and replacement of the ascending aorta after AADTA with aortic and mitral insufficiency. Mitral valve repair was achieved by quadrangular resection of the posterior leaflet, combined with ring annuloplasty. Aortic valve repair was achieved by Cabrol commissural sutures with resuspension of the annulus. The postoperative clinical course was uneventful and an echocardiogram revealed competent mitral and aortic valves. Mitral and aortic valve repair is an option in AADTA with mitral and aortic valve insufficiency.

Surgical treatment of culture-negative aortic infective endocarditis.

BACKGROUND: We retrospectively analyzed the results of operations done for culture-negative aortic infective endocarditis at a single center over a period of 26 years. METHODS: From June 1985 to January 2011, we operated on 82 patients with infective endocarditis of the aortic valve for which the results of culture were negative. Sixty-five of the patients (79.3%) were male and the patients' mean age was 38.0±14.4 years (range, 9 to 73 years). Nineteen of the patients (23.2%) had a history of previous cardiac surgery, and 16 of the patients (19.5%) had endocarditis of a prosthetic valve. Two patients (2.4%) had conduction blocks. The mean duration of follow-up was 7.1±4.3 years (range, 0.1 to 16.9 years), yielding a total of 477.0 patient-years for the study population. RESULTS: One hundred and thirty-eight procedures were done on the 82 patients in the study. The most common procedure was aortic valve replacement, which was done on 67 patients (81.7%). Thirty-nine patients (47.6%) had concomitant procedures done on the mitral valve. In-hospital death occurred in 14 patients (17.1%). Postoperatively, 17 patients (20.7%) had a low cardiac output and 9 patients (11.0%) had heart block, of whom 3 required implantation of a permanent pacemaker. The actuarial rate of survival of the patient population at 1, 5, 10, and 15 years was 92.5%±3.2%, 85.6%±4.5%, 82.5±5.3%, and 72.2±10.7% respectively. CONCLUSIONS: Culture-negative infective endocarditis is a major problem in the diagnosis and treatment of a significant proportion of cases of endocarditis. Most of the affected patients are in a healed state, which could be a cause of negative culture results. In-hospital mortality in patients with culture-negative infective aortic endocarditis is associated with a history of previous cardiac surgery, whereas long-term mortality in this patient population is associated with nonaortic procedures.

Treatment protocol and relapses of brucella endocarditis; cotrimoxazole in combination with the treatment of brucella endocarditis.

Antibiotic treatment, surgical intervention and postoperative antibiotic regimens are recommended for the treatment of brucella endocarditis (BE). Our clinical antibiotic regimens involve a triple antibiotic regimen for treating BE before the operation. The combination of three antibiotics is continued for at least six months and until the titres of the Wright serologic test are diminished to 1:160 levels. In this study, our aim was to evaluate the effects of combined medical and surgical treatments on survival and relapse rates in the periods of mid to late terms. We investigated 13 patients who were treated between January 1993 and June 2009. Our clinical observations led us to use a combination of rifampicin (900 mg twice a day), streptomycin (12 to 16 mg/kg/24 h intramuscularly) and doxycycline (200 mg/kg twice a day); rifampicin, tetracycline (8 mg/kg three times a day) and cotrimoxazole (15 mg/kg twice a day) or rifampicin, doxycycline and cotrimoxazole regimen for treating BE before the operation. This treatment should be continued for at least six months after surgery in order to prevent relapses.

The effects of reactive hyperemia on stimulation of endothelium-derived nitric oxide in on-pump and off-pump coronary artery bypass surgeries.

The purpose of this study is to compare the effects of cardiopulmonary bypass (CPB) on the endothelium-derived nitric oxide (NO) levels in on-pump and off-pump coronary artery bypass surgeries. Forty consecutive patients were divided randomly into two groups depending on use of CPB in coronary artery bypass graft surgery (group 1: n = 20, off-pump, and group 2: n = 20, on-pump). The plasma endothelium-derived NO levels were determined at baseline and after reactive hyperemia before and after surgery. Reactive hyperemia was induced by inflating a blood pressure cuff placed on the upper forearm, for 5 min at 250 mm Hg followed by a rapid deflation. Blood was collected at 1 min after cuff deflation from the radial artery on the same side. Preoperative use of all medications was recorded. The baseline plasma NO levels before operation were 17.10 ± 7.58 in group 1 and 15.49 ± 5.26 nmol/L in group 2. Before operation after reactive hyperemia, the plasma NO levels were 26.97 ± 11.49 in group 1 and 26.57 ± 12.87 nmol/L in group 2. Two hours after surgery, the plasma NO levels at baseline and after reactive hyperemia were not significantly different from each other (group 1: 18.03 ± 6.37 and group 2: 19.89 ± 9.83 nmol/L; group 1: 27.89 ± 18.36 and group 2: 39.13 ± 23.60 nmol/L, respectively; P > 0.05). A positive correlation was shown between preoperative nitroglycerine use and the postoperative plasma NO levels after reactive hyperemia (r = 0.51, P = 0.001). Linear regression analysis was performed (F = 4.10, R = 0.56, R(2) = 0.32, P = 0.008) and the only independent parameter that had an effect on postoperative plasma NO levels after reactive hyperemia was found to be preoperative nitroglycerine use (t = 3.68, P = 0.001). Coronary artery bypass surgery with CPB does not have significant effect on plasma endothelial derived NO levels. The postoperative plasma NO levels after reactive hyperemia significantly correlated with preoperative nitroglycerine use.

The impact of preoperative left ventricular ejection fraction on short and mid-term outcomes in ischaemic mitral valve repair.

BACKGROUND: It has been well established that reduced left ventriclular ejection fraction (LVEF) has adverse impact on the outcome of patients undergoing ischaemic mitral valve repair. However, the exact value of LVEF which should be used for risk stratification, has not been well established. AIM: To asses which preoperative LVEF (pLVEF) value has the best predictive value in patients undergoing ischaemic mitral valve repair. METHODS: A retrospective analysis of 105 patients with ischaemic mitral regurgitation (IMR) treated between January 2003 and June 2009 was conducted. Patients were divided into two groups according to their pLVEF value. The primary endpoints were early in-hospital and late follow-up deaths. RESULTS: The pLVEF cut-off value was determined based on univariate analysis of parameters for primary end-points. The investigated parameters were: age, pLVEF, postoperative NYHA, postoperative mitral regurgitation and postoperative LVEF. The Cox proportional hazard regression analysis identified pLVEF (HR 1.5; 95% CI 1.4-5.0; p < 0.008) as the only independent predictor of the primary end-point. The pLVEF cut-off value of 40% was found to have the highest sensitivity of 76% and specificity of 70% in predicting death. Patients were divided into two groups using the cut-off value of pLVEF of 40%. The compromised group (pLVEF < 40%) of 34 patients and the uncompromised group (pLVEF > 40%) of 71 patients had inhospital death rates of three (9%) vs two (3%) (NS) and five year mortality of 18 (54%), eight (11%) (p < 0.001), respectively. CONCLUSIONS: In IMR surgery, a pLVEF value of 40% is an important prognostic marker for mid-term survival.

Results of mitral valve repair in rheumatic mitral lesions.

BACKGROUND: We compared results for repairs of rheumatic pure mitral regurgitation (MR) and mixed mitral stenosis (MS) and MR during early and midterm time intervals. METHODS: We retrospectively analyzed 173 patients (mean age 47.6 +/- 15.1 years; 64 males) who underwent surgery for rheumatic heart disease during the period from January 1998 to June 2008. According to transvalvular mitral gradient, 91 patients had pure MR (group MR) and 82 (47%) had mixed MS-MR (group MS/MR). Preoperative and operative characteristics, postoperative MR severity, operative mortality, and early and midterm survival were examined for each surgical group. RESULTS: Preoperativley 153 patients (90.7%) were in New York Heart Association class III or IV. The most frequent pathology was leaflet prolapse (147 patients, 85.0%) and the most commonly performed procedure was annuloplasty (162 patients, 93.6%). Early mortality was similar for both groups (3.2% versus 1.2%; P = .621). The average duration of follow-up was 4.0 +/- 2.4 years (a total of 679.1 patient years). Logistic regression analysis results indicated that subvalvular repairs were related to mortality. There were no significant differences in early mortality rate, valve-related morbidity, or reoperations. CONCLUSION: Group MS/MR had more postoperative MR severity, and higher New York Heart Association class, but both groups had similar mortality and morbidity at the midterm survival point. Our results suggest that combined MS and MR repair can be performed as safely as pure MR.