Evaluation of the possible involvement of Ad-36-induced adipogenesis and coronary artery disease development in mediastinal adipose tissue samples.

Mediastinal fat has been suggested to be associated with cardiovascular diseases such as carotid stiffness, atherosclerosis and coronary artery calcification. We investigated the possible role of Ad-36-induced obesity in the pathogenesis of the coronary artery disease (CAD). Ad-36 DNA was investigated in the anterior mediastinal fat tissue samples of obese adults with CAD. Seventy-five obese adults with left main coronary artery (LMCA) disease, 28 non-obese adults with valvular heart diseases, and 48 healthy individuals without cardiovascular problems were included as the obese patient group (OPG), non-obese patient group (NOG) and healthy control group (HCG), respectively. We also simultaneously investigated Ad-36 antibodies by serum neutralization test (SNA), and measured leptin and adinopectin levels. Ad-36 antibodies were detected only in 10 patients (13.3%) within the 75 OPG. A statistically significant difference was detected between OPG, NOG and HCG in terms of Ad-36 antibody positivity (p>0.05). Ad-36 DNA was not detected in mediastinal tissue samples of OPG and NOP without PCR inhibitors. We suggest that Ad-36 may not have an affinity for mediastinal adipose tissue in obese patients with left main CAD and valvular heart diseases. Ad-36 antibody positivity results are not sufficient to reach a causal relationship.

Assessment of the association between the presence of fragmented QRS and the predicted risk score of sudden cardiac death at 5 years in patients with hypertrophic cardiomyopathy.

OBJECTIVE: It has been shown that the presence of fragmented QRS (fQRS) is associated with poor prognosis in many cardiovascular diseases and in patients with hypertrophic cardiomyopathy (HCM). However, no study has shown an association with the absolute risk score of sudden cardiac death. The aim of this study was to determine the relationship between QRS and the predicted risk score of sudden cardiac death at 5 years (HCM Risk-SCD) in HCM patients. METHODS: In total, 115 consecutive HCM patients were included in this prospective observational study. The patients were divided into two groups according to the presence [fQRS(+) group (n=65)] or absence [fQRS(-) group (n=50)] of fQRS on a 12-lead electrocardiogram (ECG). RESULTS: The HCM Risk-SCD (%) HCM Risk-SCD (>6%) values and some echocardiographic parameters, including ventricular extrasystole, ventricular tachycardia, cardiopulmonary resuscitation, implantable cardioverter defibrillator implantation, appropriate shock, and heart failure at the time of admission, were significantly higher in the fQRS(+) group than in the fQRS(-) group (all p<0.05). Both univariate and multivariate analyses revealed fQRS and New York Heart Association (NYHA) class as independent predictors of HCM Risk-SCD. In a receiver operating characteristic (ROC) curve analysis, an HCM Risk-SCD value of >4 was identified as an effective cut-off point in fQRS for HCM. An HCM Risk-SCD value of >4 yielded a sensitivity of 77% and a specificity of 76%. CONCLUSION: fQRS is determined to be an independent high-risk indicator of HCM Risk-SCD. It seems to be associated with increased ventricular arrhythmias and some echocardiographic parameters.

The importance of the neutrophil-to-lymphocyte ratio in patients with hypertrophic cardiomyopathy.

INTRODUCTION: Previous studies have demonstrated the predictive value of the neutrophil-to-lymphocyte ratio (NLR) in many cardiovascular disorders. The aim of this study was to assess whether NLR is associated with echocardiographic or electrocardiographic parameters, or with predicted five-year risk of sudden cardiac death (SCD), in patients with hypertrophic cardiomyopathy (HCM). METHODS: This prospective observational study included 74 controls and 97 HCM patients. Three years of follow-up results for HCM patients were evaluated. RESULTS: NLR was significantly higher in patients with fragmented QRS, ventricular tachycardia, and presyncope than in those without (p=0.031, 0.030, and 0.020, respectively). NLR was significantly higher in patients whose predicted five-year risk of SCD was more than 6% and whose corrected QT interval was greater than 440 ms (p=0.022 and 0.001, respectively). It was also significantly higher in patients whose left ventricular ejection fraction (LVEF) was <60% than in those with LVEF >60% (p=0.017). CONCLUSION: NLR was significantly higher in patients with HCM compared to the control group. A high NLR is associated with a higher five-year risk of SCD in patients with HCM.

Robotic surgery for atrial septal defect closure in a case of Kabuki syndrome.

Kabuki syndrome is a rare congenital malformation syndrome characterized by mental retardation, skeletal deformities, auditory dysfunction, cardiac defects, and distinctive facial appearance. Although complex cardiovascular malformations present in early childhood, rarely, atrioventricular septal defects may also present in young adults. Presently described is case of a 22-year-old female with KS who presented with ostium secundum atrial septal defect with deficient rim and idiopathic thrombocytopenic purpura. In this case, minimally invasive robotic surgery was preferred for closure of atrial septal defect.

Robot-Assisted Mitral Valve Repair With Posterior Leaflet Extension for Rheumatic Disease.

Mitral valve repair has been one of the widely used applications of robotic surgery. Patients with rheumatic mitral disease usually present at an early age with thickening, retraction, or fusion of the leaflets and subvalvular apparatus. Robotic mitral repair can be feasible among this group of patients, rather than replacement. Herein, we describe a young woman who presented with rheumatic mitral valve insufficiency. A complex mitral repair with posterior leaflet extension with an autologous pericardial patch was successfully conducted using robot assistance.

Robotic atrial septal defect closure and tricuspid annuloplasty in a case of situs inversus totalis with dextrocardia.

Situs inversus totalis (SIT) with dextrocardia is an uncommon congenital positional anomaly, which is characterized by a symmetrical 'mirror-image' orientation of all organs in relation to the midline. Although sternotomy and thoracotomy is traditionally used in patients with SIT with dextrocardia, a totally endoscopic robotic surgery is an alternative surgical approach to intracardiac anomalies. Placement of robotic ports, transthoracic aortic clamp, cardioplegia delivery, and peripheral vascular cannulation is made from the left side of the chest, as a mirror orientation of the right-sided robotic cardiac procedures. Here, we present a patient who underwent concomitant robotic atrial septal defect closure and tricuspid annuloplasty with posterior plication using the da Vinci surgical system.

Alterations in antioxidant and oxidant status of children after on-pump surgery for cyanotic and acyanotic congenital heart diseases.

OBJECTIVE: Oxidative stress refers to an imbalance between reactive oxidative species and antioxidants. In this case-controlled, prospective, observational study, we investigated the total oxidant status, total antioxidant status, oxidative stress index, and albumin and C-reactive protein levels of children with cyanotic and acyanotic congenital heart diseases who had undergone on-pump cardiac surgery. METHOD: The study groups consisted of 60 patients with congenital heart disease, who were operated under cardiopulmonary bypass, and a control group of 30 healthy individuals. The patients were classified into two groups. Among them, one was a patient group that consisted of 30 patients with acyanotic congenital heart disease and the other group consisted of 30 patients with cyanotic congenital heart disease. In the patient groups, blood samples were collected before surgery and at one and 24 hours following surgery. In control groups, blood samples were collected once during hospital admission. RESULTS: No statistically significant differences were found between the groups in terms of baseline total oxidant status, total antioxidant status, and oxidative stress index values. Regarding the postoperative first-hour and 24-hour total oxidant status and total antioxidant status levels as well as oxidative stress index values, there were no significant differences between the groups, except for an increase in total antioxidant status levels (p=0.002) 24 hours after surgery in cyanotic patients. CONCLUSION: There was no difference between oxidative stress status of cyanotic and acyanotic congenital heart disease patients and healthy individuals. Oxidative stress status of cyanotic and acyanotic patients does not change after cardiac surgery under cardiopulmonary bypass.

Surgical Transapical Approach for Prosthetic Mitral Paravalvular Leak Closure: Early Results.

The objective is to demonstrate safety and early clinical results of surgical transapical closure of paravalvular leaks (PVLs) following mitral valve replacement in significant regurgitation. Between March 2014 and February 2015, 12 patients (mean age 52.1 ± 6.0 years, 66.6% male) with severe symptomatic mitral PVLs (n = 13) underwent surgical transapical closure procedure through left mini-thoracotomy. All patients were in NYHA functional class III-IV and median logistic EuroSCORE was 24.2 ± 6.4% (range, 13.5-34.6%). Indications were heart failure (n = 10) and symptomatic hemolysis (n = 2) due to severe mitral regurgitation (MR). Amplatzer Vascular Plug-III devices (n = 9) were used for smaller and regular defects; whereas Atrial Septal Defect closure devices (n = 4) were used for larger defects. Technical success was achieved in 10 (83.3%) patients. One (8.5%) patient with 2 + MR was treated medically. A patient with residual 4 + MR underwent re-operation. There was no procedure-related complication including mortality, device migration, embolization, or cardiac laceration. Mean procedure and fluoroscopy times were 166.4 ± 39.5 (range, 90-210) and 25.7 ± 17.3 (range, 16-64) minutes, respectively. The mean intensive care and hospital stays were 2.1 ± 1.3 and 10.3 ± 6.5 days, respectively. Clinical efficacy was achieved in 9 (75%) of 12 patients at early follow-up of 8.5 ± 2.1 months. NYHA status was class II in two patients, and no hemolytic anemia was diagnosed. Echocardiographic studies revealed a significant reduction of preoperative MR (3-4+) to less than 1+ MR after operations (P < 0.05). Surgical transapical approach to PVL closure is a safe and effective procedure following mitral valve replacement. Early results show that this procedure can be an alternative to re-operation for high-risk patients. Further studies are needed to prove its effectiveness in the long term.

Hemodynamics of patient-specific aorta-pulmonary shunt configurations.

Optimal hemodynamics in aorta-pulmonary shunt reconstruction is essential for improved post-operative recovery of the newborn congenital heart disease patient. However, prior to in vivo execution, the prediction of post-operative hemodynamics is extremely challenging due to the interplay of multiple confounding physiological factors. It is hypothesized that the post-operative performance of the surgical shunt can be predicted through computational blood flow simulations that consider patient size, shunt configuration, cardiac output and the complex three-dimensional disease anatomy. Utilizing only the routine patient-specific pre-surgery clinical data sets, we demonstrated an intelligent decision-making process for a real patient having pulmonary artery atresia and ventricular septal defect. For this patient, a total of 12 customized candidate shunt configurations are contemplated and reconstructed virtually using a sketch-based computer-aided anatomical editing tool. Candidate shunt configurations are evaluated based on the parameters that are computed from the flow simulations, which include 3D flow complexity, outlet flow splits, shunt patency, coronary perfusion and energy loss. Our results showed that the modified Blalock-Taussig (mBT) shunt has 12% higher right pulmonary artery (RPA) and 40% lower left pulmonary artery (LPA) flow compared to the central shunt configuration. Also, the RPA flow regime is distinct from the LPA, creating an uneven flow split at the pulmonary arteries. For all three shunt sizes, right mBT innominate and central configurations cause higher pulmonary artery (PA) flow and lower coronary artery pressure than right and left mBT subclavian configurations. While there is a trade-off between energy loss, flow split and coronary artery pressure, overall, the mBT shunts provide sufficient PA perfusion with higher coronary artery pressures and could be preferred for similar patients having PA overflow risk. Central shunts would be preferred otherwise particularly for cases with very low PA overflow risk.

Assessment of children with vascular ring.

BACKGROUND: Vascular rings may cause pressure on the trachea and/or esophagus of varying degree, resulting in symptoms. This study assessed the presentation symptoms, diagnostic methods and treatment results after surgery in children with vascular ring. METHODS: Symptomatic vascular ring patients undergoing surgery between January 2010 and August 2014 at Mehmet Akif Ersoy Cardiovascular Research and Training Hospital, Istanbul, were retrospectively assessed. The presentation symptoms, demographic characteristics, and diagnostic tests were evaluated. Operative data and postoperative follow up, complications and problems were also examined in detail. RESULTS: Twenty-one patients underwent surgery, 13 (63%) of whom were male. Median age was 12 months (range, 1 month-8 years). Among these patients, 62% (n = 13) had double aortic arch, 24% (n = 5) had right-sided aortic arch + ligamentum arteriosum, 10% (n = 2) had left-sided aortic arch + aberrant right subclavian artery, and 4% (n = 1) had pulmonary sling abnormality. Computed tomography (CT) angiography was performed in 17/21 patients. All the patients were successfully operated on. In the early postoperative period, two patients had chylothorax and one had nerve paralysis of nervus laryngeus recurrens. One patient died in the early period, and two patients had ongoing stridor on follow up. CONCLUSIONS: CT angiography is effective for the differential diagnosis and visualization of vascular ring abnormality. In such cases, full recovery can be assured with early diagnosis and surgery.

The use of neonatal extracorporeal life support in pediatric cardiac intensive care unit.

AIM: The aim of the study is to evaluate extracorporeal life support system (ECLS) employed in neonates in pediatric cardiac intensive care unit. MATERIAL AND METHODS: Twenty-five neonates that required ECLS in between November 2010 and November 2015 were evaluated. RESULTS: The median age was 12 days (range 3-28 days) and the median body weight was 3 kg (range 2.5-5 kg). Venoarterial ECLS was performed in all of the cases. Ascendan aorta-right atrial cannulation in 22 patients and neck cannulation in three patients were performed. The reason for ECLS was E-CPR in two patients, inability to wean from cardiopulmonary bypass (CPB) in seven patients, respiratory insufficiency and hypoxia in nine patients, low cardiac output (LCOS) in seven patients. Median duration of ECLS was four days (range 1-15). Hemorrhagic complications developed in 15, renal complications in 13, pulmonary complications in 12, infectious complications in 11, neurologic complications in three and mechanical complications in two of the patients. Weaning was successful in 15 of the patients. Eleven patients were successfully discharged. CONCLUSION: ECLS is an important treatment option that is performed successfully in many centers around the world to maintain life support in patients unresponsive to medical treatment. The utilization of this modality especially in newborns with congenital heart disease should be taken into consideration.

Comparison of Edwards Sapien XT versus Lotus Valve Devices in Terms of Electrophysiological Study Parameters in Patients Undergoing TAVI.

BACKGROUND: The purpose of this study is to assess the electrocardiographic and electrophysiological parameters of conduction abnormalities in patients undergoing transcatheter aortic valve implantation (TAVI) due to severe aortic valve stenosis. METHODS: The study included 55 patients who underwent TAVI using either the Boston Scientific Lotus (n:25) (Boston Scientific, Natick, MA, USA) or Edwards Sapien XT (n:30) (Edwards Lifesciences, Irvine, CA, USA) prostheses. An electrophysiological study (EPS) was performed in the catheterization room immediately before the initial balloon valvuloplasty and immediately after prosthesis implantation. RESULTS: QRS duration and His-bundle to His-ventricle (HV) intervals, which were similar between the two groups before the procedure, were found to be significantly higher in the Lotus valve group postprocedure. Permanent pacemakers (PPMs) were required more frequently in the Lotus group than in the Sapien XT group at discharge (24.0% vs 6.7%, P = 0.07). With the exception of a higher prevalence of paravalvular leakage (P < 0.001) in patients undergoing Sapien XT implantation, other clinical outcomes were similar between the two groups. Multiple regression analysis revealed that baseline atrioventricular (AV) conduction disorders and HV intervals after the procedure were independently associated with PPM implantation after TAVI. CONCLUSION: In this first study comparing the findings of EPS and electrocardiography, the impact of the Lotus valve on AV conduction systems was greater than that of the Sapien XT. However, the need for PPM was higher in the Lotus valve than in the Sapien XT. PPM requirement is related to valve design; it may decrease with reduced frame height and metal burden in novel valve systems.

Totally endoscopic robotic repair of coronary sinus atrial septal defect.

Coronary sinus atrial septal defect is a rare congenital cardiac anomaly in adults. Patients with this anomaly are generally treated using conventional sternotomy or thoracotomy incisions. However, robotic surgery can be a feasible alternative in this anomaly. We report an adult patient, who presented with coronary sinus atrial septal defect. A totally endoscopic robotic repair was successfully done through a right atriotomy approach in this patient.

Use of inhaled nitric oxide in pediatric cardiac intensive care unit.

OBJECTIVE: Experience with administration of inhaled nitric oxide (iNO) in pediatric cardiac intensive care unit was retrospectively reviewed. METHODS: Data from 32 pediatric patients treated with iNO between 2011 and 2012 were collected. Patients were divided into 3 groups: Group I comprised postoperative patients, Group II comprised newborns with persistent pulmonary hypertension (PPH), and Group III comprised patients with primary pulmonary hypertension (PH) or Eisenmenger's syndrome. Age, sex, weight, primary diagnosis, arterial blood sample, pulmonary artery pressure (PAP), systemic arterial pressure (SAP), and oxygen saturation levels were analyzed. RESULTS: Groups I, II, and III included 25, 3, and 4 patients, respectively. Median weight was 8 kg (range: 3-40 kg), and median age was 7 months (range: 2 days-10 years). On average, iNO treatment was initiated at the 12th hour after admission to the unit (range: 1-48 hours) and continued for a median duration of 24 hours (range: 12-168 hours). Systolic PAP was 40±15 mmHg, mean SAP was 57±18 mmHg, PAP/SAP ratio was 0.69, and oxygen saturation levels were 88% prior to iNO treatment. Following iNO treatment, PAP decreased to 24±9 mmHg (p<0.05), PAP/SAP ratio decreased to 0.4 (p<0.05), SAP showed no change (60±12 mmHg), and saturation levels increased to 98% (p<0.05). Seven patients died during follow-up (Group I, n=5; Group II, n=1; Group III, n=1). CONCLUSION: iNO seems to effectively reduce PAP, and can be used effectively and safely to prevent pulmonary hypertensive crises in pediatric cardiac intensive care units.

Use of an Intrapericardial Continuous Flow Ventricular Assist Device in a 4-Year-Old Child Weighing 12 Kilograms.

Ventricular assist devices are implanted in patients with intractable heart failure as a bridge to cardiac transplantation to support the circulatory system mechanically. We present a report of a continuous flow ventricular assist device successfully placed as a bridge to transplantation in the intrapericardium of a petite-sized child with a BSA of 0.56 m2. Not only is the use of an intrapericardial, continuous-flow, centrifugal pump feasible for destination therapy, but also for low-weight pediatric patients with end-stage heart failure as a bridge to transplantation when there is chronic shortage of donor organs for heart transplantation. Consequently, the HeartWare system has been implanted in smaller patients with acceptable results, and this patient may be the youngest ever reported.

Robot-Assisted Repair of Right Partial Anomalous Pulmonary Venous Return.

Partial anomalous venous return from the right lung to the right atrium is a rare congenital heart anomaly in adults. We report a 20-year-old female, who presented with right partial anomalous pulmonary venous return and an associated inferior atrial septal defect. A complex repair was successfully done through a right atriotomy approach using a robotic surgical system. doi: 10.1111/jocs.12753 (J Card Surg 2016;31:394-397).

Robotic Mitral Valve Replacement in Pectus Excavatum.

Exposure of the mitral valve can be challenging using conventional sternotomy and thoracotomy incisions in patients with pectus deformity. We report the use of a robotic approach to replace a rheumatic mitral valve in a patient with pectus excavatum. doi: 10.1111/jocs.12740 (J Card Surg 2016;31:306-308).

A New Specific Device in Transcatheter Prosthetic Paravalvular Leak Closure: A Prospective Two-Center Trial.

BACKGROUND: This study sought to compare various outcomes among a new specifically designed transcatheter paravalvular leak closure (TPVLC) device and the devices that are being utilized off-label. METHODS: Between April 2012 and January 2015, in a prospective two-center study, 52 patients who needed surgical reintervention due to a hemodynamically significant prosthetic paravalvular leak were studied. This study population was divided into two groups. Group I was composed of 32 patients who underwent paravalvular leak (PVL) closure with the currently available devices that are being utilized off-label, while group II consisted of 20 patients who were treated with the new specifically designed Occlutech PVL device. RESULTS: Demographic and clinical variables indicated a higher rate of atrial fibrillation (P = 0.027) and chronic obstructive airway disease (P = 0.009) in group II. The apical approach was the most commonly used intervention route used for group II (P = 0.019). The procedural success rate was 100% (29 of 29 leaks) in group II while the rate was 92% (39 of 42 leaks) in group I. However, more secondary events were observed in group I, but they did not reach statistical significance (8 vs. 1, P = 0.064). CONCLUSIONS: With its high procedural success rate and encouraging outcome results, the Occlutech device seems to satisfy the expectations of a specifically designed PVL closure device. © 2016 Wiley Periodicals, Inc.