Comparison of Beating-Heart Technique Versus Aortic Cross-Clamping in Tricuspid Valve Surgery.

OBJECTIVE: Tricuspid valve surgery can be performed on a beating heart or on an arrested heart. We aimed to compare the outcomes of tricuspid valve surgery using these two different approaches. METHODS: Between January 2015 and February 2020, 204 patients who underwent tricuspid valve surgery along with concomitant cardiac surgical procedures were included in the study. Techniques of cross-clamping and beating-heart tricuspid surgery were applied to 103 and 101 patients, respectively. Concomitant valvular and/or coronary interventions were performed under cross clamping in both groups. Results from the preoperative period, immediate postoperative period, and six-month postoperative interval were compared between the groups. RESULTS: There were no differences in demographic characteristics or preoperative grades of tricuspid valve regurgitation between the groups. Duration of mechanical ventilation, and stays in the intensive care unit and hospital were significantly shorter in patients operated on using the beating-heart technique. Additionally, re-exploration surgery and mortality rates were significantly lower in the beating-heart group. Postoperative six-month echocardiography findings related to tricuspid valve regurgitation, maximum and minimum gradients of the tricuspid valve, and pulmonary arterial pressure were also lower in the beating-heart group. CONCLUSION: Beating-heart tricuspid valve surgery may be preferable to the cross-clamping technique to avoid clamp-induced ischemia, which can lead to worsened postoperative outcomes.

Surgical and Histopathological Results in Carotid Body Tumors.

OBJECTIVE: The possible relationships between the histopathological findings of carotid body tumors and age, gender, tumor diameter, and Shamblin classification were investigated. In addition, preoperative embolization status, development of neurological complications, need for vascular reconstruction, hemoglobin change, and discharge time were examined and the effects of these variables on each other were analyzed. METHODS: Between 2008 and 2022, 46 cases who underwent carotid body tumor excision were examined retrospectively. The cases were followed for an average of 81 months postoperatively. Histopathological materials were reexamined and the effect of categorical variables was analyzed. RESULTS: Mean tumor diameter was 3.55 ± 1.26 cm, mean discharge time was 3.91 ± 2.37 days, and mean hemoglobin change was 1.86 ± 1.25. Neurological complications developed in 13% of cases. The amount of hemoglobin change was significantly (p = 0.003) higher in those who developed neurological complications, whereas the tumor diameter and discharge time were found to be insignificantly higher. Surgical complications requiring vascular repair occurred in 10.8% of cases. Tumor diameter (p = 0.017) and hemoglobin change (p = 0.046) were significantly higher in these patients. There were significant correlations between higher Shamblin classification and tumor diameter, discharge time, postoperative hemoglobin value, and number of surgical and neurological complications. No significant difference was found between Ki-67, capsular invasion, mitosis, pleomorphism, prominent nucleoli, mean island diameter, and tendency of islands to merge with categorical variables. CONCLUSION: As the tumor diameter increases, the operation becomes more difficult and the postoperative complication rate increases. We think that subadventitial and capsular removal of the tumor is effective in preventing recurrence. To reach a histopathological conclusion, a larger series of studies including tumors with high Ki-67 and mitosis rates, large size, and one or more of the criteria for necrosis are needed.

The effects of botulinum toxin A and papaverine on human saphenous vein and internal mammary artery grafts: an in vitro study.

Introduction: Autologous saphenous vein (SV) and internal mammary artery (IMA) are used as bypass conduits during coronary artery bypass graft surgery. Vasospasm of the arterial and venous grafts may constitute a significant clinical problem. Pretreatment with a vasodilator drug of the graft ex vivo or intraluminal injection before implantation may be used for spasm prophylaxis. This in vitro study was designed to assess the vasoactive effects and time-dependent changes of botulinum toxin A (BTX-A) and papaverine pretreatment on vasospasm of human SV and IMA grafts. Also, histomorphology of the vessels was assessed. Material and methods: SV and IMA segments were suspended in organ baths, and isometric contraction responses to 2 different concentrations of 5-hydroxytryptamine (5-HT) and endothelin-1 (ET-1) were recorded after incubation with 2 different concentrations of BTX-A and papaverine at 2 time points (0 h and 2 h). Results: The results revealed the following: 1) incubation with BTX-A and papaverine relaxes both SV and IMA rings contracted with 5-HT and ET-1; 2) the duration of the relaxant effect of BTX-A lasts longer than papaverine; and 3) no apparent histomorphological changes were observed in the grafts under light microscopy. Conclusions: This study demonstrates that in human SV and IMA grafts, pretreatment with both BTX-A and papaverine are safe and have a potent inhibitory effect depending on the vessel and vasoconstrictor agent. The long-lasting vasodilatory effect of BTX-A on vascular smooth muscle may provide promising results in the prevention of venous and arterial graft spasm.

Assessing volumetric changes in abdominal aortic aneurysms following endovascular repair.

OBJECTIVE: Volumetric changes in the aneurysm sac were evaluated following endovascular aortic repair (EVAR) in intact abdominal aortic aneurysm (AAA) patients who underwent EVAR. METHODS: Fifty-two patients, who underwent EVAR from 2015 to 2019, were analysed retrospectively. A total of 158 computed tomography angiography scans was examined by performing reconsctructive volumetric calculations. Total aneurysm volume (TAV), patent lumen volume (PLV) and thrombuscoated aneurysm wall volume (TCAWV) were calculated. The results obtained at six, 12 and 24 months postoperatively were compared with those of the pre-operative period. RESULTS: Mean TAV had regressed 7% by the sixth month (p = 0.1), 27% by the 12th month (p = 0.0003) and 19% by the 24th month (p = 0.0008). Mean TCAWV had increased 2% by the sixth month (p = 0.3), and regressed 26% by the 12th month (p = 0.3) and 14% by the 24th month (p = 0.8). Mean PLV had regressed by 20% by the sixth month (p = 0.008), 29% by the 12th month (p = 0.0002) and 26% by the 24th month (p = 0.0006). For each individual proximal, middle and distal measurement, regression was observed at six and 12 months; however, an increase was observed at 24 months compared to the previous follow ups. CONCLUSIONS: The expansion measurements of TAV in the 24th month support the doubts on the medium- to long-term results of EVAR. The largest regression in the aneurysm sac was observed in the distal portion, then in the proximal portion, and the least regression was observed in the middle section.

Predictive Value of Neutrophil-to-Lymphocyte, Aspartate-to-Alanine Aminotransferase, Lymphocyte-to-Monocyte and Platelet-to-Lymphocyte Ratios in Severity and Side of Carotid Artery Stenosis: Are Those Significant?

BACKGROUND: Atherosclerosis is a chronic disease that leads to mortality and morbidity by affecting arterial vascular structures. Carotid artery is one of these arterial structures and occlusive disease of carotid artery may cause stroke or cranial ischemic infarction. Inflammation plays a role in the atherosclerotic process. In this study, we aimed to discuss the relationship between the severity and side of carotid artery occlusion and novel inflammatory parameters include platelet-to-lymphocyte, neutrophil-to- lymphocyte, lymphocyte-to-monocyte, and aspartate-to-alanine aminotransferase ratios. METHODS: One-hundred-fifteen patients who had carotid artery stenosis between 50%-99% and 115 healthy subjects with no carotid artery stenosis or additional disease were included in the study. The relationship between the side and degree of the lesion and platelet-to-lymphocyte, neutrophil-to-lymphocyte, lymphocyte-to-monocyte, and aspartate-to-alanine aminotransferase ratios were studied in the patient group. The patients with carotid artery stenosis and the healthy subjects were compared, in the terms of same parameters. Data were evaluated statistically. RESULTS: There were no statistically significant differences between the groups, in the terms of platelet-to-lymphocyte, neutrophil-to-lymphocyte, lymphocyte-to-monocyte, and aspartate-to-alanine aminotransferase ratios and the degree of stenosis. There was no statistically significant difference between the sides of the lesions and the parameters above except lymphocyte-to-monocyte ratio. It was statistically significantly higher in left-sided lesions. Aspartate-to- alanine aminotransferase and neutrophil-to-lymphocyte ratios were markedly higher in the patient group, when compared to controls. CONCLUSION: Platelet-to-lymphocyte, neutrophil-to-lymphocyte, lymphocyte-to-monocyte, and aspartate-to- alanine aminotransferase ratios are inexpensive, easy, fast, and reproducible parameters that can be used in determining the prediction of carotid artery stenosis.

Management of Cardiac Surgery in a Pandemic Region Hospital: Precautions, Results and Experiences During COVID-19.

OBJECTIVE: The aim of the present study was to share the experiences gained from emergency and semiemergency cases of open heart surgery performed during the COVID-19 outbreak in Necmettin Erbakan University Meram Medical Faculty Hospital, which was defined as a pandemic hospital by Turkish Ministry of Health and provided third degree health services. MATERIALS AND METHODS: A total of 54 patients were retrospectively analyzed between 23 March and 22 May 2020, who were diagnosed to have aortic dissection, coronary artery disease, and heart valve diseases. RESULTS: Thirty-two CABG, 12 valve surgery, 6 aortic surgery, 4 CABG + valve surgeries were performed. During the postoperative follow-up of 11 patients, who were suspicious of COVID-19, 8 of them displayed respiratory problems and partial oxygen depletion and required continuous positive airway pressure. The hospitalization duration of COVID-19-suspicious patients were approximately 5 days longer than that of normal patients. In one of the patient, who was treated positive for COVID-19, acute coronary syndrome developed and CABG was performed following the treatment. CONCLUSION: During the pandemic period, acute cardiac diseases needing urgent surgery could be misdiagnosed because of similar symptoms with COVID-19 and the health care practitioners concentrated with the COVID-19 primarily. On the other hand, pandemic fear could cause delayed admission to the hospital and increased postoperative mortality and morbidity. When a COVID-19-positive or -suspicious patient undergo open-heart surgery, problems resulting from both COVID-19 infection and cardiopulmonary bypass-associated systemic effects could arise. The combination of these two cases could worsen the complications.

Comparison between the Effects of Bretschneider's HTK Solution and Cold Blood Cardioplegia on Systemic Endothelial Functions in Patients who Undergo Coronary Artery Bypass Surgery: a Prospective Randomized and Controlled Trial.

OBJECTIVE: To investigate the effects of Bretschneider's histidine-tryptophan-ketoglutarate (HTK) solution and cold blood cardioplegia on systemic endothelial functions. METHODS: A total of 50 patients who underwent isolated coronary artery bypass surgery between March 2018 and May 2018 were randomly divided into two groups - group 1 (Bretschneider's HTK solution, n=25) and group 2 (cold blood cardioplegia, n=25). Data related to the indicators of endothelial dysfunction were recorded. Flow-mediated dilation was measured together with the assessment of the values of endothelin-1, von Willebrand factor, and asymmetric dimethylarginine to identify endothelial dysfunction. Then, the two groups were compared regarding these values. RESULTS: The most significant result of our study was that the endothelin-1 level was significantly higher in group 2 than in group 1 (P<0.001). The value of flow-mediated dilation was found to increase to a lesser degree on the postoperative days compared to the value at the day of admission in group 1 (P=0.002 and P=0.030, respectively). CONCLUSION: Cardiopulmonary bypass leads to endothelial dysfunction. Our results revealed that Bretschneider's HTK solution causes less severe endothelial injury than cold blood cardioplegia.

Comparison between the effects of bretschneiders htk solution and cold blood cardioplegia on systemic endothelial functions in patients who undergo coronary artery bypass surgery: a prospective randomized and controlled trial

Abstract Objective: To investigate the effects of Bretschneider's histidine-tryptophan-ketoglutarate (HTK) solution and cold blood cardioplegia on systemic endothelial functions. Methods: A total of 50 patients who underwent isolated coronary artery bypass surgery between March 2018 and May 2018 were randomly divided into two groups - group 1 (Bretschneider's HTK solution, n=25) and group 2 (cold blood cardioplegia, n=25). Data related to the indicators of endothelial dysfunction were recorded. Flow-mediated dilation was measured together with the assessment of the values of endothelin-1, von Willebrand factor, and asymmetric dimethylarginine to identify endothelial dysfunction. Then, the two groups were compared regarding these values. Results: The most significant result of our study was that the endothelin-1 level was significantly higher in group 2 than in group 1 (P<0.001). The value of flow-mediated dilation was found to increase to a lesser degree on the postoperative days compared to the value at the day of admission in group 1 (P=0.002 and P=0.030, respectively). Conclusion: Cardiopulmonary bypass leads to endothelial dysfunction. Our results revealed that Bretschneider's HTK solution causes less severe endothelial injury than cold blood cardioplegia.

Relaxation matters: comparison of in-vitro vasodilatory role of botulinum toxin-A and papaverine in human radial artery grafts.

BACKGROUND: Radial artery (RA) is widely used in coronary artery bypass (CABG) surgery and the prevention of spasm is crucial for graft patency. Botulinum toxin A (BTX-A) and B are commonly used for aesthetic reasons and neuromuscular disorders. They are proven to raise blood flow and increase survival of ischemic skin flaps. In this study we evaluated and compared the vasodilator effects of BTX-A and papaverine on human RA grafts. METHODS: After resting 60 min in isolated organ baths, human RA grafts were examined. Contraction responses for different doses of serotonin (5-HT) and endothelin-1 (ET-1) were evaluated as a percent of maximum contraction response elicited by 80 mM potassium chloride (KCl). The inhibitory effects of BTX-A and papaverine on contraction responses taken at the 0th hour were compared with the 1st and 2nd hour responses. Inhibitory effects of BTX-A and papaverine against the contractile agent were evaluated by comparing the results of the first and last (0th and 2nd hour) application. RESULTS: In low concentrations, when we compared the effects of BTX-A (10- 8 M) and papaverine (10- 6 M) on 5-HT, papaverine was found to be more effective at both the 0th and 2nd hour (p < 0.05). Both BTX-A and papaverine inhibited the maximum contractile effect of ET-1 to the same extent at the 0th hour; but, the inhibitory effect of BTX-A was significantly stronger at the 2nd hour (p < 0.05). In high concentrations, when we compared the effects of BTX-A (10- 6 M) and papaverine (10- 4 M) on 5-HT, papaverine showed stronger inhibition (p < 0.05), whereas both agents had similar action of inhibition on ET-1 mediated maximum contraction responses. CONCLUSION: BTX-A inhibits both ET-1 and 5-HT induced contractions and its effectiveness does not decrease over time as observed with papaverine. This study is the first in the literature using human RA for prevention of vasospasm by BTX-A.

Gradual treatment of arteriovenous fistula in femoral vessels as a complication of coronary angiography

Abstract Arteriovenous fistula due to coronary angiography intervention is rarely seen. Arteriovenous fistulas may be asymptomatic according to the size of the shunt, as well as to the heart failure. In this case report, we aimed to share gradual transition from endovascular methods to surgery and why surgical treatment is required for a patient who developed arteriovenous fistula after coronary angiography.

Left Atrial Giant Cell Myocarditis Presenting as a Tumor: First-in-Man Case Report.

Giant cell myocarditis is a rare and highly lethal disorder with resultant cardiac insufficiency. It necessitates aggressive immune suppression therapy, although the results are often fatal. When it affects only the atria, the characteristics of the disease changes completely. In this case report, we present atypical presentation of atrial giant cell myocarditis with mass lesion, which completely resolved after successful surgical resection without immuno suppression therapy.

Left atrial giant cell myocarditis presenting as a tumor: first-in-man case report

Abstract Giant cell myocarditis is a rare and highly lethal disorder with resultant cardiac insufficiency. It necessitates aggressive immune suppression therapy, although the results are often fatal. When it affects only the atria, the characteristics of the disease changes completely. In this case report, we present atypical presentation of atrial giant cell myocarditis with mass lesion, which completely resolved after successful surgical resection without immuno suppression therapy.

Transaortic accessory mitral valve excision in an adult patient: Case report.

Accessory mitral valve tissue is a rare congenital cardiac anomaly, and is usually incidentally detected in childhood. In this case, we present a 65-year-old man with aortic stenosis originating from an accessory mitral valve leaflet attached to the anterior mitral leaflet. Interestingly enough, the patient's accessory mitral valve remained undetected for years until he became symptomatic for degenerative aortic stenosis. Aortic valve replacement and excision of the accessory mitral valve attached to the anterior mitral leaflet was performed with a transaortic approach instead of atriotomy. It was also unusual to see accessory mitral valve tissue with aortic stenosis instead of other frequently associated congenital anomalies.

Gradual Treatment of Arteriovenous Fistula in Femoral Vessels as a Complication of Coronary Angiography.

Arteriovenous fistula due to coronary angiography intervention is rarely seen. Arteriovenous fistulas may be asymptomatic according to the size of the shunt, as well as to the heart failure. In this case report, we aimed to share gradual transition from endovascular methods to surgery and why surgical treatment is required for a patient who developed arteriovenous fistula after coronary angiography.

Safety of once- or twice-daily dosing of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with nonvalvular atrial fibrillation: A NOAC-TR study.

Once-daily dosing of non-vitamin K antagonist oral anticoagulants (NOACs) may increase patient adherence to treatment but may also be associated with a higher risk of bleeding. In this study, we investigated the adherence to once- or twice-daily dosing of NOACs and the risk of bleeding in nonvalvular atrial fibrillation (NVAF) patients. This multicenter cross-sectional study, conducted between 1 September 2015 and 28 February 2016, included 2214 patients receiving NOACs for at least 3 months, due to NVAF. Patients receiving once-daily or twice-daily NOAC doses were 1:1 propensity score matched for baseline demographic characteristics and the presence of other diseases. The medication adherence was assessed by the 8-item Morisky Medication Adherence Scale. Risk factors were investigated in relation to minor and major bleeding. The mean age of patients was 71 ± 10 years, and 53% of the patients were women. The medication adherence was lower in patients receiving twice-daily NOAC doses compared to once-daily-dose group (47% versus 53%, p = 0.001), and there was no difference between the groups in terms of minor (15% versus 16%, p = 0.292) and major bleeding (3% versus 3%, p = 0.796). Independent risk factors for bleeding were non-adherence to medication (OR: 1.62, 95% CI: 1.23-2.14, p = 0.001), presence of 3 or more other diseases (OR: 10.3, 95% CI: 5.3-20.3, p < 0.001), and HAS-BLED (Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile INR, Elderly, Drugs or alcohol) score (OR: 4.84, 95% CI: 4.04-5.8, p < 0.001). In summary, the once-daily dose of NOACs was associated with increased patient adherence to medication, while it was not associated with bleeding complications.

Full metal jacket: transfemoral aortic valve implantation for regurgitant valve after endovascular aortic repair.

Transfemoral aortic valve implantation has become an almost routine interventional procedure for severe aortic stenosis in high-risk patients. Over time an increased number of experiences has led to unusual procedures. In this report, we present a successful valve-in-valve transfemoral aortic valve implantation in a patient with aortic regurgitation, who previously had debranching and thoracic endovascular aortic repair operations.

The Time in Therapeutic Range and Bleeding Complications of Warfarin in Different Geographic Regions of Turkey: A Subgroup Analysis of WARFARIN-TR Study.

BACKGROUND: The time in therapeutic range values may vary between different geographical regions of Turkey in patients vitamin K antagonist therapy. AIMS: To evaluate the time in therapeutic range percentages, efficacy, safety and awareness of warfarin according to the different geographical regions in patients who participated in the WARFARIN-TR study (The Awareness, Efficacy, Safety and Time in Therapeutic Range of Warfarin in the Turkish population) in Turkey. STUDY DESIGN: Cross-sectional study. METHODS: The WARFARIN-TR study includes 4987 patients using warfarin and involved regular international normalized ratio monitoring between January 1, 2014 and December 31, 2014. Patients attended follow-ups for 12 months. The sample size calculations were analysed according to the density of the regional population and according to Turkish Statistical Institute data. The time in therapeutic range was calculated according to F.R. Roosendaal's algorithm. Awareness was evaluated based on the patients' knowledge of the effect of warfarin and food-drug interactions with simple questions developed based on a literature review. RESULTS: The Turkey-wide time in therapeutic range was reported as 49.5%±22.9 in the WARFARIN-TR study. There were statistically significant differences between regions in terms of time in therapeutic range (p>0.001). The highest rate was reported in the Marmara region (54.99%±20.91) and the lowest was in the South-eastern Anatolia region (41.95±24.15) (p>0.001). Bleeding events were most frequently seen in Eastern Anatolia (41.6%), with major bleeding in the Aegean region (5.11%) and South-eastern Anatolia (5.36%). There were statistically significant differences between the regions in terms of awareness (p>0.001). CONCLUSION: Statistically significant differences were observed in terms of the efficacy, safety and awareness of warfarin therapy according to different geographical regions in Turkey.

New World's old disease: cardiac hydatid disease and surgical principles.

BACKGROUND: Hydatid cyst is a parasitic disease caused by infection with the Echinococcus granulosus tapeworm larva. It is a major public health problem in endemic regions. Cardiac involvement of the disease is rare. METHODS: Between 1985 and 2015, 12 patients were admitted to our clinic with a possible diagnosis of cardiac hydatid disease. Of these patients, six (50%) were male and six (50%) were female. Mean age of the patients was 42.6 years. RESULTS: The most common location of cardiac hydatid disease was left sided (six patients, 50%). Five (41.7%) patients had cysts located in the right heart, whereas one (8.3%) had a cyst in the interventricular septum. Eleven (91.7%) of the patients were operated on via median sternotomy and the remaining one was operated on via a left anterolateral thoracotomy. Ten (83.3%) of the patients were operated on using cardiopulmonary bypass under moderate hypothermia, whereas the remaining two (16.7%) had off-pump surgery. There was no surgical mortality in our series. All patients were discharged with medical therapy (mebendazole or albendazole) for the duration of six months. No recurrences were observed in their follow ups. CONCLUSION: Although cardiac hydatid disease is rare, its prevalence seems to have increased in the last decade. Any patient with suspected cardiac symptoms suggesting mass lesions should be considered for a differential diagnosis of cardiac hydatid disease, especially in developing countries. Definitive treatment is removal of the cyst, combined with medical therapy.

[Evaluation of post-operative flow and diameter changes in brachial and ulnar arteries in coronary artery bypass surgery patients in which the radial artery is used as graft]. / Koroner arter baypas cerrahisinde radiyal arter grefti kullanilan hastalarda ameliyat sonrasi dönemde brakiyal ve ulnar arterlerde meydana gelen akim ve çap degisikliklerinin incelenmesi.

OBJECTIVE: The radial artery is widely used in coronary bypass surgery. In these patients, forearm and hand circulation is provided by the ulnar artery. This study aimed to investigate post-operative changes in flow and diameter in brachial and ulnar arteries in patients undergoing coronary bypass surgery in which the radial artery is used as graft. METHODS: Between September 2007 and September 2008, 20 patients (16 men, 4 women; mean age 57.8 years; range 44 to 70 years) underwent elective coronary bypass surgery at our clinic. The radial artery was used as graft in all cases. Pre-operatively, adequacy of the ulnar artery for forearm circulation was investigated by Allen test and duplex ultrasonography. Basal flow and diameter values of the brachial and ulnar arteries were measured. Control duplex ultrasound measurements were performed at three months post-operatively. Flow and diameter changes in the brachial and ulnar arteries were recorded. RESULTS: Significant increase was shown in ulnar artery flow and diameter values in post-operative measurements. A significant increase was observed in brachial artery diameter, accompanied by a relative decrease in flow value. There were no mortality or ischemic complications in our study. Transient paresthesia as a neurological complication was observed in 4 patients. CONCLUSION: Radial artery use for coronary bypass surgery leads to significant changes in ulnar and brachial arteries. All flow and diameter changes can be detected by color Doppler ultrasonography in the early stages. These adaptation mechanisms show that the radial artery can be safely harvested as graft material.