Long-term follow-up of patients with Buerger's disease after autologous stem cell therapy.

OBJECTIVE: We investigated the long-term results of autologous bone marrow mononuclear cells (ABMMNCs) implantation in patients with Buerger's disease (BD). METHODS: Twenty-eight patients (25 males and 3 females) who had BD and critical unilateral limb ischemia were investigated between April 2003 and August 2005. The patients were administered multiple injections of CD34+ and CD45+ positive ABMMNCs into the gastrocnemius muscle, the intermetatarsal region, and the dorsum of the foot (n=26) or forearm (n=2) and saline injection into the contralateral limb. RESULTS: The mean follow-up time was 139.6±10.5 months. No complication related to stem cell therapy was observed during the follow-up. The ankle-brachial pressure index evaluated at 6 months and 120 months was compared to the baseline scores (p<0.001 and p=0.021, respectively). Digital subtraction angiography (DSA) was performed for all patients at baseline, 6 months, and 120 months. The angiographic improvement was 78.5% and 57.1% at 6 and 120 months, respectively. Patients demonstrated a significant improvement in the quality of life parameters at 6 months compared to baseline (p=0.008) and 120 months compared to the baseline (p=0.009). The 10-year amputation-free rate was 96% (95% CI=0.71-1) in ABMMNC-implanted limbs and 93% (95% CI=0.33-0.94) in saline-injected limbs (p=1). CONCLUSION: Autologous stem cell therapy could be an alternative therapeutic method for BD at long-term follow-up.

Clinical Results of Cardiac Surgery in Patients with Chronic Hepatitis C and Their Role in Risk Models: A Case-Control Study.

BACKGROUND: To evaluate the results of patients with chronic hepatitis C virus (HCV) following cardiac surgery in the TurcoSCORE (TrS) database. METHODS: Sixty patients with HCV who underwent cardiac surgery between 2005 and 2016 in our clinic out of a total 8,018 patients from the TrS database were included in the study. The perioperative morbidity and mortality rates in these patients were compared with a matched cohort. RESULTS: The mean follow-up time was 96.6 ± 12.3 months. Hospital mortality rates (HCV group 5% vs. control group 1.7%, p = 0.61) were similar between the groups. No significant difference was found in the duration of cardiopulmonary bypass (HCV 79.1 ± 12.3 vs. control 82.6 ± 11.8, p = 0.88) and cross clamps (HCV 33.4 ± 6.9 vs control 33.8 ± 7.2 p = 0.76) between the two groups. The rate of patients who were revised due to postoperative hemorrhage was significantly higher in the HCV arm compared with the matched cohort (HCV 13.3% vs. control 1.7%, p < 0.05). Although the measured prothrombin time (PT) and international normalized ratio (INR) in the postoperative 24th hour were in normal ranges in both arms, they were significantly higher in the HCV arm (HCV 11.2 ± 1.2 vs. control 10.5 ± 0.8, p < 0.05; HCV 0.99 ± 0.06, vs. control 0.92 ± 0.03, p < 0.0001). CONCLUSION: The presence of HCV can be an important prognostic factor for morbidity in patients undergoing cardiac surgery. It can also play an important role in the risk models generated for cardiac surgery.

Pharmacomechanical thrombectomy of upper extremity deep vein thrombosis.

BACKGROUND: This study aims to evaluate the efficacy and safety of ultrasound-accelerated catheter-directed thrombolysis (UACDT) in the treatment of upper extremity deep vein thrombosis (UEDVT). METHODS: We conducted a prospective, observational cohort study of consecutive patients with acute UEDVT with low-dose UACDT using the Ekosonic® Endovascular System (EKOS Corporation, Bothell, WA, USA) at a single center from September 2012 until October 2014. Overall, sixteen patients (11 males and 6 females, age range 18 to 70 years, mean age, 45.6 years) were included in the study protocol. The primary efficacy outcome was complete thrombus clearance. The primary safety outcomes were recurrence of thrombosis within the follow-up visit and major bleeding within 96 hours of the procedure initiation. RESULTS: The median tissue plasminogen activator (tPA) dose for all patients in our study was 16.81±2.51 mg (range 15 to 28 mg) and the median infusion time was 15 hours. Complete thrombus clearance was achieved in 11 (68.8%) patients, and partial clearance was detected in 3 (18.8%) patients. Of 16 patients with UEDVT, two had gastrointestinal bleeding, and two had puncture site bleeding. CONCLUSIONS: This prospective study demonstrates effectiveness and safety of ultrasound accelerated thrombolysis in patients with UEDVT.

Native valve Brucella endocarditis.

OBJECTIVE: Brucellosis is frequently seen in Mediterranean and Middle East countries, including Turkey. We report the medical and surgical management of 31 cases of native endocarditis. MATERIAL AND METHOD: Thirty-one patients were admitted to our clinic with suspected Brucella Endocarditis. The diagnosis was established by either isolation of Brucella species, or the presence of antibodies. Following preoperative antibiotic therapy patients underwent valve replacement with excessive tissue debridement. Patients were followed up with Brucella titers, blood cultures, and echocardiography. RESULTS: On admission all patients were febrile and mostly dyspneic (NYHA Class 3 or 4). The blood tests were normal except for elevated ESR, CRP and serological tests. The aortic valve was involved in 19 patients, mitral valve in 7 patients, and both valves in 5. After serological confirmation of BE, antibiotic therapy was maintained. Twenty-five of the patients received rifampicine, doxycycline, and cotrimaxozole; 2 of them received a combination of rifampicine, streptomycin, and doxycycline; and 4 of them received rifampicine, tetracycline, and cotrimaxozole. Tissue loss in most of the affected leaflets and vegetations were presenting all patients. Valve replacements were performed with mechanical and biologic prostheses. All the patients were afebrile at discharge but received the antibiotics for 101, 2+/-16, 9 days. The follow-up was 37, 1+/-9, 2 months. DISCUSSION: In our retrospective study, combination of adequate medical and surgical therapy resulted in declined morbidity and mortality rate. The valve replacement with aggressive debridement is the most important part of the treatment, which should be supported with efficient preoperative and long term postoperative medical treatment.

Relationship between functional promoter polymorphism in the XBP1 gene (-116C/G) and atherosclerosis, ischemic stroke and hyperhomocysteinemia.

ER stress is associated with a range of pathological conditions, among which, the ischemia/reperfusion injury is also found. The mechanistic array of links among the ER stress and thrombovascular diseases is poorly understood. The XBP1 gene is a transcription factor which modulates the ER stress response; and the XBP1 (-116 C/G) gene polymorphism causes an impairment of its positive feedback system. In the present study we investigated the prevalence of XBP1 gene (-116 C/G) polymorphism, separately among the patients with atherosclerosis, ischemic stroke and hyperhomocysteinemia. The G allele and the (-116 G/G) genotype of the XBP1 (-116 C/G) gene polymorphism were found to be a significant risk factor for the patients with Ischemic Stroke. Yet, this allele was seemingly less significant in case of patients with atherosclerosis and hyperhomocysteinemia. Hence, the XBP1 (-116 C/G) gene polymorphism and especially its involvement in a homozygous state are suggested to take active role in the ER stress related ischemia/reperfusion injury.

Effect of posterior pericardial drainage on the incidence of pericardial effusion after ascending aortic surgery.

OBJECTIVE: Pericardial effusion and cardiac tamponade after ascending aortic surgery are higher than anticipated after cardiac surgery. We evaluated a thin closed-suction drain system to prevent posterior pericardial effusion in patients undergoing ascending aortic surgery. METHODS: One hundred forty patients who underwent ascending aortic surgery were prospectively randomized into group A and group B. In group A (n = 70) we used a 32F drain placed anteriorly overlying the heart and a 16F thin drain placed retrocardially. In group B (n = 70) only a 32F drain placed anteriorly was used. In group A we removed the large drain on the first postoperative day and continued drainage with the thin drain until the drainage was less than 50 mL in a 24-hour period. In group B we removed the drain after the first postoperative day when the drainage was less than 50 mL in an 8-hour period. Preoperative, perioperative, and postoperative parameters of the patients were compared. RESULTS: No significant posterior pericardial effusion and late cardiac tamponade developed in patients in group A. In group B 10 (14.3%) patients experienced significant posterior pericardial effusion and 4 (5.7%) patients experienced late cardiac tamponade; the incidence of significant pericardial effusion in group B was significantly higher (P = .001). Postoperative new-onset atrial fibrillation developed in 6 (10.4%) patients in group A and in 18 (32.7%) patients in group B (P = .03). CONCLUSIONS: We demonstrated that effective posterior drainage is important to prevent posterior pericardial effusion, and use of a thin drain placed retrocardially appears to be sufficient for these results.

Therapeutic Angiogenesis by Autologous Transplantation of Bone Marrow Mononuclear Cells for Buerger's Patients with Retractable Limb Ischaemia: A Preliminary Report.

Bone marrow implantation into ischaemic limbs could enhance angiogenesis by supplying endothelialprogeniter cells and angiogenic cytokinesot factors. We investigated efficacy and safety of autologousimplantation of bonemarrow-mononuclearcells (BMMC)in patients with ischaemic limbs due to Buerger's disease. We commence daciinical study to test cell therapy with autologous BMMC in patients with ischaemic limbs at the University of Ankara School of Medicine. In order for the patients to qualify for BMMC implantation, they should have critical limb ischaemia define das ischaemic rest painin a limb with or without non healing ulcers, should not respond to previous iloprost infusions and smoking cessation six months prior to evaluation and should not be candidates for nonsurgicalor surgical revascularisation. Primaryend points were safety andfeasibility of the treatmentand total healing of the most importantlesion. Secondary endpoints were total relief of rest pain without the need for analgesies,change in peak walkingtime (PWT)at 12 weeks, improvements in ankle-brachial pressure index(ABI), transcutaneous oxygen saturation using pulse oximetry(SaO2),angiographic evidence of newcollatera lvesselformation, tissue perfusion in the affected extremity using Thallium perfusions cintigraphyW. hilepatients(meanage46.7: !: 10.3years)were undergeneraal naesthesiaw, eharvested bonemarrow(519: t 45.5mUfromtheposteridilriacspineA. fterredbloodcell(RBCd) epletiaannd volumereduction using a continuous flow cell separator,we achieved 91% RBC depletian and concentrated /~MMC to a final volume and concentration of 51.5: t io.1 mLand7.04: t 1.9 x ioe7/mL total nucleated cells, respectively W.eimplantedBMMC (mean12.16: t 4.3 x ioe8) within three hours after marrow aspiration by intramuscular injection into the gastrocnemiusmuscle of ischaemic legs. Isotonic saline were injected into the other extremityin as similar fashion as control. 13 Unilateral intramuscular administration of BMMC was not associated with any complications. The primary efficacy end point, total healing of the most importantlesion, was achieved in three patients. All patients were followed up for at least four weeks. The secondary measures; change in PWT(LlPWT)at 12 weeks, total relief of rest pain without the need of analgesics improved in three patjents. These improvements were sustained for 24 weeks in the first two patients. Digital subtraction angiographic studies before and 3 months after the BMMC implantation showed the presence of a new vascular collateral network across the affected arteries in three patients. Preliminary results of the presentedstudy are promising. Thus, bone marrow maybe a potential source of cells for Buerger'spatients with end-stage Iimbischaemia refractory to other medical treatment modalities.

Surgery for cardiac hydatid disease: an Anatolian experience.

OBJECTIVE: The purpose of this study was to describe the clinical/pathological features and the outcome of the surgical treatment of cardiac hydatid disease in our unit and other hospitals of Anatolia over a fifteen-years period. METHODS: Between 1984 and 2001, fifty cases of surgically treated cardiac hydatid disease were identified by systematic literature search from Anatolia. Twelve patients were operated at the Department of Cardiovascular Surgery, Ankara University within the same period. Overall thirty-nine patients were female (mean age 29.8+/-14 years). Sixty-three percent of patients were complaining of dyspnea at the time of referral to the hospital and 22% presented with signs of acute coronary syndrome. RESULTS: The most common cardiac location was the left ventricle (46.7%) followed by the interventricular septum, the right ventricle and atria. The most common procedure was controlled puncture and aspiration of the cyst content, its excision and closure of the resulting cavity, which were performed under cardiopulmonary bypass. Overall Anatolian operative mortality was 4.8% (3 patients). No late deaths but recurrence in one patient have occurred. CONCLUSION: In view of the lack of efficient alternative treatment options, we recommend surgical intervention even in asymptomatic patients in order to prevent the occurrence of lethal complications.

[Alternative approaches in the end-stage heart failure]. / Ileri Dönem Kalp Yetmezliginde Alternatif Arayislar.

Cardiac transplantation has emerged as the therapeutic procedure of choice for patients with end-stage heart disease but the availability of donor organs remains major limiting factor allowing only 1% of the candidates actually become transplant recipients. New therapeutic strategies are under intensive research for patients who do not meet patient selection criteria for transplantation or who suffer from donor organ shortage. Even though there are significant developments in the medical treatment of cardiac failure, the prognosis of this condition continues to be poor. The 20-40% of the candidates for cardiac transplantation die while they are included in the waiting list. Twenty percent mortality has been reported within the first year of transplantation with additional yearly mortality of 5% following the first year. Financial constraints, complications of immunosuppression and functional failure of the transplanted hearts are other limiting factors. This has brought up the necessity to search for alternative surgical treatment methods besides increasing the waiting periods of transplant candidates. The aim of this report is to summarize other currently available therapeutic alternatives for patients with end-stage cardiac disease.

Early experience with Shelhigh stentless composite valve. A complete biological replacement of ascending aorta.

BACKGROUND: Currently, Shelhigh Stentless Composite Valve (SSCV) is the only complete biological conduit available on the market for this purpose. SSCV has been used to avoid anticoagulation with the advantage of established haemodynamic benefits of stentless valves as well as for its surgeon-friendly surgical implantation. METHODS: Between August 1999 and January 2001, 11 patients (8 women, 3 men, mean age 71.5+/-9.3 years) underwent first time aortic root and ascending aorta replacement with SSCV in Leicester. Aortic regurgitation was found in seven patients and aortic stenosis was predominant in three. Mean preoperative NYHA functional class was 24+/-0.7 and mean Parsonnet score was 25.1+/-1.1. Mean preoperative aortic root diameter was 5.34+/-1.2 cm, left ventricular (LV) end-systolic diameter was 4.3+/-0.5, and end-diastolic diameter was 6.5+/-0.6 cm. Preoperative LV ejection fraction was less than 30% in 6 (55%) patients. One patient had additional aortic arch replacement and three patients had concomitant myocardial revascularisation. Seven patients received size 25 mm SSVC, and four patients received size 27 mm SSCV. All patients had Doppler echocardiographic studies before discharge from the hospital and current follow-up data are available for all patients. RESULTS: All patients survived the early postoperative period, however, one patient developed transient stroke. While no biological glue or teflon were used during surgery, no patient required re-operation for bleeding and there was no significant blood loss recorded postoperatively. Mean postoperative intensive care stay was 1.5+/-0.7 and hospital stay was 11.3+/-4.9 days. Postoperative mean gradients were 9.7+/-3.05 mmHg for 25 mm grafts, and 8.6+/-4.3 mmHg for 27 mm composite grafts. CONCLUSIONS: Early experience with the SSCV used for the replacement of ascending aorta is encouraging. Practical benefits include improved haemostatic suture line, established haemodynamic advantages of a stentless valve and surgeon-friendly implantation while avoiding long-term anticoagulation.

Do women live longer following lung resection for carcinoma?

OBJECTIVE: To determine whether patient gender affects the outlook following lung resection for non-small cell lung cancer (NSCLC). PATIENTS AND METHODS: Prospectively collected data on 833 patients undergoing lung resection for NSCLC between 1990 and 2000 in a single unit were analysed. RESULTS: 581 patients were male (mean age 64.7 +/- 7 years) and 252 were female (mean age 62.6 +/- 7.8 years) (P=0.006). Male patients were more likely to have a history of ischaemic heart disease (P=0.03), to have poorer preoperative spirometry as demonstrated by their % predicted FEV1 (P=0.02) and to need pneumonectomy (P=0.0001) than their female counterparts. Squamous cell carcinoma was the predominant histological cell type in men and adenocarcinoma in women (P<0.0001). There was a trend towards a lower pathological stage among women, but this was not significant. Operative mortality for men was 4.6 and 1.2% for women (P=0.01). Overall 5-year survival for men was 34.2 +/- 2.65% and 47.5 +/ - 4.2% for women (P=0.001) and, for the hospital survivors, was 36.5 +/- 2.7% and 48.1 +/- 4.2%, respectively (P=0.01). On univariate analysis, older age, the need for pneumonectomy and higher pathological stage were significant adverse factors whereas squamous cell type and female gender were significant favourable factors for survival (P<0.05). On Cox proportional hazards model (with and without hospital deaths), pathological stage (P<0.0001), female gender (P=0.0006) and squamous cell type (P=0.001) were independent predictors of survival. The survival was significantly better for women having squamous cell (P=0.01) or non-squamous cell cancers (adenocarcinoma and other) (P=0.002). Regarding the stage, women had a significant survival advantage at pathological stage I (P=0.01) and a relatively better survival at stage II and stage III disease (P=0.3). CONCLUSIONS: This study suggests that female gender exerts a significant positive effect on survival following lung resection for NSCLC. This effect is pronounced at early disease stage and persists after adjusting for important differences in the clinical, histo-pathological features and extent of pulmonary resection between male and female patients.