Predicting Amputation Rates in Acute Limb Ischemia: Is the Neutrophil-Lymphocyte Ratio a Reliable Indicator?

Objective This study aimed to investigate the causes of amputation and the associated biochemical parameters in patients with acute limb ischemia (ALI). Methods Patients who presented to our clinic with ALI between January 2012 and January 2022 were deemed eligible for participation. Patients who developed ALI owing to atherosclerosis or atrial fibrillation were included in the study. In contrast, patients who developed ALI owing to trauma, iatrogenic causes, or popliteal artery aneurysms were excluded. Patients' demographic data, biochemical parameters, and hemogram values at the time of admission were retrospectively analyzed. Results A total of 374 patients were included in the study. Of them, 57.82% (n = 218) were male and 42.18% (n= 156) were female. Amputation was required in 7.95% (n = 30) of the patients after presenting with ALI and receiving necessary surgical or medical intervention. Multivariate analysis revealed the symptom-to-door time to be the primary factor determining the need for amputation in patients. With each passing hour following the manifestation of symptoms, the risk of amputation increased by 1.3 times [odds ratio (OR): 1.289%, 95% confidence interval (CI): 1.079-1.540 p = 0.05]. The neutrophil-to-lymphocyte ratio (NLR) and other hematological parameters had no effect on amputation in both univariate and multivariate analyses (OR: 1.49%; 95% CI: 0.977-2.287 p = 0.512). Conclusions Based on our findings, the main factor affecting the need for amputation in ALI patients was the symptom-to-door time. Biochemical and hematological parameters had no effect on amputation in ALI.

Tricuspid repair: short and long-term results of suture annuloplasty techniques and rigid and flexible ring annuloplasty techniques.

BACKGROUND: Functional tricuspid regurgitation may arise from left heart valve diseases or other factors. If not addressed concurrently with primary surgical intervention, it may contribute to increased morbidity and mortality rates during the postoperative period. This study investigates the impact of various repair techniques on crucial factors such as systolic pulmonary artery pressure (SPAP), tricuspid valve regurgitation, and New York Heart Association (NYHA) functional capacity class in the postoperative period. MATERIALS AND METHODS: From April 2007 to June 2013, 379 adults underwent open-heart surgery for functional tricuspid regurgitation. Patients were categorized into four groups: Group 1 (156) with De Vega suture annuloplasty, Group 2 (60) with Kay suture annuloplasty, Group 3 (122) with Flexible Duran ring annuloplasty, and Group 4 (41) with Semi-Rigid Carpentier-Edwards ring annuloplasty. Demographic, clinical, operative, and postoperative data were recorded over a mean follow-up of 35.6 ± 19.1 months. Postoperative SPAP values, tricuspid regurgitation grades, and NYHA functional capacity classes were compared among the groups. RESULTS: No statistically significant differences were observed among the groups regarding age, gender, preoperative disease diagnoses, history of previous cardiac operations, or echocardiographic characteristics such as preoperative ejection fraction, SPAP, and tricuspid regurgitation. Hospital and intensive care unit length of stay and postoperative complications also showed no significant differences. However, patients in Group 3 exhibited longer Cardio-Pulmonary Bypass duration, cross-clamp duration, and higher positive inotrope requirements. While the mortality rate within the first 30 days was higher in Group 1 compared to the other groups (p: 0.011), overall mortality rates did not significantly differ among the groups. Significant regression in functional tricuspid regurgitation and a notable decrease in SPAP values were observed in patients from Group 3 and Group 4 (p: 0.001). Additionally, patients in Group 3 and Group 4 showed a more significant reduction in NYHA functional capacity classification during the postoperative period (p: 0.001). CONCLUSION: Among the repair techniques, ring annuloplasty demonstrated superiority in reducing SPAP, regressing tricuspid regurgitation, and improving NYHA functional capacity in functional tricuspid regurgitation repairs.

Factors Affecting Recanalization in Femoropopliteal Deep Vein Thrombosis.

Effects of warfarin and new-generation direct oral anticoagulants (DOACs) on thrombus resolution after the treatment of deep vein thrombosis (DVT) are still unknown. The study aimed to investigate the effects of warfarin and DOACs on thrombus resolution after DVT treatment. Methods: The study included 666 patients who were diagnosed with femoropopliteal DVT between January 2016 and January 2022 and had complete medical records without missing data. Patients with and without recanalization were added to groups 1 (n = 396) and 2 (n = 270), respectively. Ultrasonography/venous Doppler examinations of the patients during follow-up were performed by 3 radiologists. Recanalization was defined as the presence of complete flow in the femoral and popliteal veins and the absence of residual venous thrombus. Results: Among the included patients, recanalization was observed in 59.5% patients. The mean follow-up period was 23.6 ± 17.8 (range 1-72; median 17) months. There was no difference between the 2 groups in terms of the types of drugs used in the treatment (P = .208). Cox regression models were used to investigate the factors affecting recanalization. Analysis of the variables having significant differences between both groups revealed the low rate of recanalization in patients with coronary artery disease (odds ratio [OR], 2.3%; 95% confidence intervals [CI]: 1.6-3.4; P < .001) and diabetes mellitus (OR, 1.5; 95% CI: 1.1-1.9; P = .009). Conclusion: Thrombus resolution after femoropopliteal DVT is not affected by the drugs used in the treatment.

Radiofrequency ablation of the great saphenous vein; does the choice of monopolar or bipolar catheters affect outcomes?

OBJECTIVES: Radiofrequency-based procedure is one of the leading methods of endovenous thermal ablation. The most fundamental difference with regards to currently available radiofrequency ablation systems is the way of electric current flow given to the vein wall; bipolar segmental and monopolar ablation. This study aimed to compare the monopolar ablation method with conventional bipolar segmental endovenous radiofrequency ablation method for the management of incompetent saphenous veins. METHODS: Between November 2019 and November 2021, 121 patients with incompetent varicose veins who were treated either with the F-Care/monopolar (N = 49) or ClosureFast/bipolar (N = 72) were included in the study. A single extremity of each patient with isolated great saphenous vein insufficiency was enrolled. The differences between the two groups in demographic parameters, disease severity, treated veins, peri- and postoperative complications, and treatment efficacy indicators were retrospectively evaluated. RESULTS: There was no statistically significant difference between the groups regarding demographic parameters, disease severity, and treated veins in preoperative period (p > 0,05). The average procedural time was 21.4 ± 4 minutes in the monopolar group, while it was 17.1 ± 3 minutes in the bipolar group. In both groups, the venous clinical severity scores declined significantly compared with the preoperative period, however; there was no difference between groups (p > 0,05). The occlusion rate of the saphenofemoral junction and proximal saphenous vein after 1 year was 94.1% in the bipolar group and 91.8% in the monopolar group (p = 0.4) while there was a significant difference in the occlusion rate of the shaft and distal part of the saphenous vein (93.2% in the bipolar group and 80.4% in the monopolar group, p = 0.04). Postoperative complications (bruising and skin pigmentation) were slightly higher in the bipolar group (p = 0.02, p = 0.01). CONCLUSIONS: Both systems are effective in treating the venous insufficiency of the lower extremity. Monopolar system revealed a better early postoperative course with similar occlusion rate of the proximal part of saphenous vein compared with bipolar system, however; the occlusion of the lower half of the saphenous vein was significantly lower which may negatively affect long-term occlusion rates and recurrence of the disease.

The impact of spontaneous echo contrast on tunneled dialysis catheter patency.

BACKGROUND: Spontaneous echo contrast (SEC) is an ultrasonographic image of swirling blood flow resembling a dynamic, cigarette smoke-like image. It is mostly observed during the insertion of tunneled dialysis catheters (TDC) into internal jugular veins with ultrasound guidance, often different levels of SEC can be seen. The aim of this study is to investigate the impact of SEC detected during TDC insertion on the patency of the catheter. METHODS: Patients who had a TDC insertion in our clinic between January 2015 and December 2020 were prospectively evaluated. The patients were grouped into five groups according to the sec level and followed. RESULTS: A total of 226 patients were examined, among which 107 were male (47.3%). The mean age of all patients was 63.1 ± 9.5 years. SEC grade and catheter occlusion was evaluated, it was observed that higher SEC grades were correlated with faster catheter thrombosis postinsertion. During the follow-up period, it was found that, compared to the SEC 0 group, catheter thrombosis occurred 3.22 times faster in the SEC 1 group, 2.66 times faster in the SEC 2 group, 5.80 times faster in the SEC 3 group, and 26.33 times faster in the SEC 4 group. (HR: 3.22, 2.66, 5.80, 26.33, respectively). Hematological parameters were evaluated by regression analysis, it was observed that hemoglobin, fibrinogen, and platelet count were not risk factors for SEC formation and SEC grade. CONCLUSION: Significant relationship was found between SEC grade detected during catheter insertion and catheter thrombosis in patients undergoing hemodialysis with a TDC.

Biocompatibility of the Oxygenator on Pulsatile Flow by Electron Microscope.

INTRODUCTION: Extracorporeal perfusion flow type requires further investigation. The aim of this study is to compare the effects of pulsatile and nonpulsatile flow on oxygenator fibers that were analyzed by scanning electron microscope (SEM) and to extensively study patients' coagulation profiles, inflammatory markers, and functional blood tests. METHODS: Twelve patients who had open heart surgery were randomly divided into two groups; the nonpulsatile flow (group NP, six patients) and pulsatile flow (group P, six patients) groups. Both superficial view and axial sections of the oxygenator fiber samples were examined under SEM to compare the thickness of absorbed blood proteins and amount of blood cells on the surface of oxygenators. Platelet count, coagulation profile, and inflammatory predictors were also studied from the blood samples. RESULTS: Fibrinogen levels after cardiopulmonary bypass were significantly lower in group NP (group P, 2.57±2.78 g/L; group NP; 2.39±0.70 g/L, P=0.03). Inflammatory biomarkers such as C-reactive protein, interleukin (IL)-6, IL-12, apelin, S100ß, and tumor necrosis factor alpha were comparable in both groups. Axial sections of the oxygenator fiber samples had a mean thickness of 45.2 µm and 46.5 µm in groups P and NP, respectively, and this difference is statistically significant (P=0.006). Superficial view of the fiber samples showed obviously lower platelet, leukocyte, and erythrocyte levels in group P. CONCLUSION: Our study demonstrated that both cellular elements and protein adsorption on oxygenator fibers are lower in the group P than in the group NP. Pulsatile perfusion has better biocompatibility on extracorporeal circulation when analyzed by SEM technique.

Atrial Fibrillation after Coronary Bypass Surgery? Is Epicardial Fat a Risk Factor?

BACKGROUNDS: Postoperative atrial fibrillation (POAF) is one of the most common complication of cardiac surgery. Epicardial fat tissue may play a role in the development of atrial fibrillation (AF). The aim of this study was to evaluate relationship between epicardial fat volume (EFV) and the appearance of new-onset AF in patients undergoing isolated coronary artery bypass graft (CABG) with normal echocardiographic functions. METHODS: Between January 2017 and June 2020, 281 coronary artery disease patients undergone isolated CABG surgery with normal echocardiographic functions were included in the study. Patient characteristics, medical history, and perioperative variables were retrospectively collected. Patients with AF predisposition factors were excluded. RESULTS: Sixty-seven patients (23.8%) developed postoperatively AF during hospital stay. In univariate analysis, patients with postoperative AF were older compared with sinus rhythm patients (60.78 ± 9.03 vs. 65.46 ± 9.22, p = 0.001). There are no statistically significant differences between groups and EFV compared (107.78 ± 41.04 vs. 106.66 ± 34.98 p = 0.84). Large left atrial diameter, female patient, cardiopulmonary bypass and longer cross-clamp time showed correlation between POAF without statistical significance. CONCLUSION: Aging is the only associated factor with AF in this study. There was no EFV difference between POAF and non-AF groups in patients undergoing isolated CABG with normal echocardiographic functions.

Adjuvant radiofrequency thermocoagulation improves the outcome of liquid sclerotherapy in the treatment of spider veins of the leg: A pilot study.

OBJECTIVE: This study evaluated the effect of low-energy radiofrequency thermocoagulation added to standard liquid sclerotherapy on clinical outcomes of patients with venous insufficiency. PATIENTS AND METHOD: We included 111 patients with spider veins CEAP/C1 stage. The patients were randomized into sclerotherapy (Group 1) and sclerotherapy + sclerotherapy immediately followed by low energy percutaneous RF thermocoagulation (Group 2) groups and followed up with same protocols prospectively. RESULTS: The study groups did not differ in terms of the mean age, body mass index, the number of spider veins and pre-interventional venous clinical severity scores (VCSS). Patients' self-assessed satisfaction ratings of cosmetic outcomes were found to be higher compared to the baseline (p = 0.001). While both techniques caused a significant decline in VCSS at postprocedural third month, it was observed that the type of applied intervention did not affect the VCSS (p = 0.43 and p = 0.93, respectively). There was a significant difference in hyperpigmentation and trapped blood between the two groups after the procedure (p = 0.009 and p = 0.02, respectively), there was no statistically significant difference in terms of skin necrosis (p = 0.52). A significant difference in the self-assessed cosmetic outcomes was observed in patients treated with sclerotherapy followed by low energy percutaneous RF thermocoagulation compared with patients whom sclerotherapy performed alone (p = 0.001). DISCUSSION: This study suggests that radiofrequency thermocoagulation added to the sclerotherapy provides better cosmetic outcomes with less treatment sessions and no additional complication rates.

Carotid artery stenosis in asymptomatic patients undergoing coronary artery bypass grafting: who and when should be screened?

BACKGROUND: Carotid artery stenosis (CAS) is one of the major causes of stroke in coronary artery bypass grafting (CABG). AIMS: The aim of this study was to determine which age groups require screening for CAS using carotid duplex ultrasound in asymptomatic patients undergoing CABG. METHODS: We included 644 neurologically asymptomatic consecutive patients (mean [SD] age, 63.9 [8.8] years; men, 453 [70.3%]) who underwent elective isolated CABG between June 2015 and June 2020. Clinical, demographic, and radiological data as well as coronary angiography results were retrospectively reviewed. Patients were classified into 4 age groups: 40 to 50, 51 to 60, 61 to 70, and >70 years, as well as 3 groups depending on the CAS degree: 50% or less, 50% to 70%, and 70% or greater. Regression analysis was applied across the selected parameters to identify risk factors for significant CAS, and receiver operating characteristic analysis, to determine cutoff age and SYNTAX score of patients who had to be screened before CABG. RESULTS: Overall, 8 (1.1%) patients included in the present study had stroke following CABG. Cutoff values of the SYNTAX score and CAS of 70% or greater were found to be 27 and 64 years, respectively. The sensitivity and specificity of the cutoff value were 98.4% to 98.3% and 74.3% to 55.1%, respectively. The area under the curve was 0.98 and 0.73, respectively. CONCLUSION: Based on the receiver operating characteristic analysis, we recommended to perform screening for CAS in patients older than 64 years and with a SYNTAX score of 27 or higher, even if they are asymptomatic.

Does uncontrolled diabetes mellitus affect cerebral hemodynamics in heart surgery?

BACKGROUND: In this study, we aimed to investigate the effects of poor blood glucose control on the intraoperative cerebral system in patients undergoing coronary artery bypass grafting using various neuromonitors. METHODS: Between January 2011 and December 2011, a total of 40 adult patients (31 males, 9 females; mean age 58.8±9.2 years; range, 38 to 78 years) who were scheduled for elective coronary artery bypass grafting were included in the study. The patients were divided into four groups according to hemoglobin A1c levels as follows: Group 1 including non-diabetic controls (n=11); Group 2 including those with a hemoglobin A1c value of <7% (n=10); Group 3 including those with a hemoglobin A1c value of 7 to 10% (n=11); and Group 4 including those with a hemoglobin A1c value of ≥10% (n=8). Cerebral monitoring was performed with near-infrared spectroscopy and transcranial Doppler. Measurement periods were defined as follows: Before anesthesia induction (period 1), 10 min after anesthesia induction (period 2), during cannulation (period 3), 10 min after cardiopulmonary bypass (period 4), at 32°C temperature during cardiopulmonary bypass (period 5), at 36°C temperature during cardiopulmonary bypass (period 6), and at the end of the operation (period 7). RESULTS: There was a significant difference in the near-infrared spectroscopy values in the cannulation period for both right (p<0.001) and left (p=0.002) sides and the mean transcranial Doppler flow velocity (p=0.002) in Group 4, compared to Group 1. The heart rate was found to be significantly lower in Group 4 in the cannulation period. The near-infrared spectroscopy values and transcranial Doppler blood flow velocity decreased in Group 4 in all measurement periods. CONCLUSION: The results of our study show that, in patients with severe diabetes undergoing open heart surgery, heart rate decreases in the cannulation period due to possible autonomic neuropathy, and cerebral blood flow and oxygenation decrease. For these patients, particularly in the cannulation period, perfusion of both cerebral and other organs should be closely monitored and necessary interventions should be performed.

Internal Jugular Vein Catheterization: The Landmark Technique versus Ultrasonography Guidance in Cardiac Surgery.

Background Central venous catheterization is an invasive procedure that must be performed during cardiovascular surgery. The addition of ultrasound guidance to the catheterization technique has shown effectiveness in reducing complications because it allows for the visualization of anatomical variations prior to intervention and the continual visualization of the needle during the placement. The purpose of this study was to evaluate the effectiveness of needle-guiding ultrasound for internal jugular venous cannulation. Method Patients undergoing coronary bypass surgery at Hitit University, department of cardiovascular surgery, from January 2014 to June 2018, were included in the study. The patients were divided into two groups: those with catheterization with ultrasound guidance (Group U) and those with catheterization performed with the anatomic landmark technique (Group L). Results A total of 584 cases were investigated. The success of the procedure and complication rates for both methods were compared. Central vein catheterization with ultrasonography produced success and complication rates significantly better than those for catheterization using the landmark technique (p=0.04 and p=0.00001, respectively). Conclusion This study demonstrated that the use of ultrasonography for internal jugular vein catheterization for patients undergoing coronary bypass surgery significantly reduced the complication rates as compared to those of patients where the landmark technique was used for catheterization.

Predictive Value of STOP-BANG on OSAS-Related Complications Following Coronary Artery Bypass Grafting.

BACKGROUND: The time and conditions may not be suitable for performing polysomnography (PSG) before urgent or emergent surgeries, for example, a coronary artery bypass graft. Unavailability in many centers, critical clinical situation, and inability to arrange a timely scheduled appointment are other limitations for PSG. In this study, we aimed to investigate if the STOP-BANG Questionnaire may predict obstructive sleep apnea syndrome (OSAS) related postoperative pulmonary alterations during coronary artery surgery. METHODS: Sixty-one subjects who were scheduled to undergo elective isolated coronary artery bypass graft surgery and were consulted for preoperative pulmonary assessment were recruited to the study. The STOP-BANG Questionnaire was used with the subjects; then their relationship with postoperative complications was assessed. RESULTS: Results of the STOP-BANG Questionnaire revealed that 36.1% of subjects were at high risk for OSAS. Three groups were established according to the STOP-BANG Questionnaire (low risk, group 1; moderate risk, group 2; high risk, group 3) and study parameters, including PEEP value in ventilator, detection of apnea at ventilator, CPAP time after extubation, SpO2 1 h after extubation, postoperative hypoxemia, need for CPAP, and ICU length of stay revealed significant relationships among these groups. CONCLUSIONS: The STOP-BANG Questionnaire may predict the OSAS risk and OSAS-related pulmonary complications for patients who are candidates for a coronary artery bypass graft and unable to be evaluated with PSG before surgery due to technical or time-related limitations.

The use of Rapid Shallow Breathing Index shortens time to extubation in patients undergoing coronary artery bypass grafting.

BACKGROUND: This study aims to investigate the effects of the use of the Rapid Shallow Breathing Index on extubation success and time to extubation in patients undergoing elective isolated coronary artery bypass grafting. METHODS: This prospective, randomized-controlled study included a total of 72 patients (55 males, 19 females; mean age 60.3±9.3 years; range 45 to 76 years) who underwent isolated coronary artery bypass grafting between February 2016 and November 2016. The patients were divided into two groups as the RSBI group (n=36) and the control group (n=36). The control group was extubated by conventional criteria that were routinely applied in our clinic, while the RSBI group was extubated, when the index scores became below 77 breaths per min/L, following ensuring hemodynamic stability and weaning procedure from mechanical ventilation. RESULTS: The mean time to wean from mechanical ventilation was 5.8±1.0 hours in the RSBI group and 8.1±2.0 hours in the control group (p=0.03). Extubation protocol performed through the use of the index was found to provide 26% earlier extubation compared to the conventional extubation criteria. There was no significant difference in the postoperative follow-up parameters or clinical conditions. CONCLUSION: Our study results show that a practical tool such as the Rapid Shallow Breathing Index can be reliably used for making a decision in favor of extubation in patients undergoing coronary artery bypass grafting. A shortened time to extubation by the use of this index may provide substantial benefits in terms of prevention of infections, mechanical ventilation-induced lung injuries, and potential pulmonary complications.

Distribution of Thoracic Aortic Calcifications in Patients Undergoing Coronary Artery Bypass Grafting.

BACKGROUND: In procedures involving surgical maneuvers such as cannulation, clamping, or proximal anastomosis where aortic manipulation is inevitable, a preliminary assessment of atherosclerotic plaques bears clinical significance. In the present study, our aim was to evaluate the frequency and distribution of aortic calcifications in patients undergoing coronary artery bypass grafting (CABG) surgery to propose a morphological classification system. METHODS: A total of 443 consecutive patients with coronary artery disease were included in this study. Preoperative non-contrast enhanced computed tomography images, in-hospital follow-up data, and patient characteristics were retrospectively evaluated. RESULTS: Whereas 33% of patients had no calcifications at any site in the aorta, 7.9%, 75.4%, and 16.7% had calcifications in the ascending aorta, aortic arch, and descending aorta, respectively. Focal small calcifications were the most common type of lesions in the ascending aorta (3.9%), whereas 9 patients (1.4%) had porcelain ascending aorta. We defined four types of patients with increasing severity and extent of calcifications. CONCLUSIONS: Based on the frequency and distribution of calcifications in the thoracic aorta, we propose a classification system from least to most severe for coronary artery disease patients who are candidates for CABG.

Spontaneous coronary artery rupture without a pericardial effusion: a diagnostic challenge.

Spontaneous coronary artery rupture (CAR) is an extremely rare, life-threatening entity. It is a challenge to make a diagnosis of CAR in the absence of pericardial effusion. We describe a case of a spontaneous rupture of the right coronary artery (RCA) without pericardial effusion that emphasises the benefit of high clinical suspicion and early diagnosis. A 60-year-old man was admitted to the emergency department, with inferior myocardial infarction. Echocardiogram was negative for a pericardial effusion. Coronary angiography revealed complete occlusion of the RCA with intraluminal dissection and extravasation of contrast into the epicardium at the mid-portion of the RCA, which suggested rupture of the RCA. The patient underwent uneventful emergency coronary artery bypass grafting. CAR should be considered as a differential diagnosis in patients with acute chest pain, even in the absence of pericardial effusion, particularly in case of inferior wall involvement.

Does really previous stenting affect graft patency following CABG? A 5-year follow-up: The effect of PCI on graft survival.

The aim of this study was to compare the graft patency rates among patients who had a previous history of percutaneous coronary intervention (PCI) followed by coronary artery bypass grafting surgery (CABG) with the patients who had experienced CABG surgery alone. The 69 patients who were included in the study had a history of bare metal stent implantation prior to CABG (group 1). The coronary angiography results were compared with 69 patients who had a previous history of CABG (group 2). Graft patency rates of the left anterior descending artery and circumflex anastomoses are statistically significant for both groups, whereas the right coronary artery anastomoses are not statistically significant (p = 0.008; 0.009; 0.2). Graft patency rate of LIMA-LAD anastomoses was 43.9 ± 10.8 % in group 1 and 86.2 ± 6 % in group 2 for means of 60 months (p = 0.0001) and circumflex coronary artery anastomosis is 28.9 ± 0.9 % in group 1, 65.7 ± 10.8 % in group 2 (p = 0.0001) and the right coronary artery anastomosis is 37.2 ± 13.6 % in group 1, 56.4 ± 8.9 % in group 2 (p = 0.0001). The graft patency rates of coronary arteries without previous stent implantation were higher than the patients with previous stent implantation and experienced CABG. The results suggest that prior PCI may induce atherosclerotic events in the vessel that can adversely affect graft patency after surgery.

Mitral Patient-Prosthesis Mismatch Predicts Suboptimal Hemodynamic Recovery after Mitral Valve Replacement.

BACKGROUND: A possible relationship between an obstructive prosthesis and suboptimal hemodynamic recovery, as reflected by unsatisfactory regression in systolic pulmonary artery pressure (sPAP) and functional tricuspid regurgitation (FTR) following mitral valve replacement (MVR), was investigated. A delineating effective orifice area index (EOAI) value was sought in order to define a patient-prosthesis mismatch. METHODS: A total of 128 patients undergoing isolated mechanical MVR were followed up for a mean of 46 ± 9 months. Patients were allocated to two groups. Group I comprised 83 patients (65%) exhibiting a satisfactory (≥30%) regression in sPAP and FTR, while group II comprised 45 patients with a <30% (suboptimal) decrease in these parameters. A cutoff value for the prosthetic mitral valve in-vivo EAOI was explored as a predictor of postoperative hemodynamic recovery. RESULTS: The mean in-vivo EOAI differed significantly between the groups (1.23 cm2/m2 in group I versus 1.11 cm2/m2 in group II; p <0.0001). The consequent receiver operating characteristic curve analysis revealed an EOAI of 1.19 cm2/m2 as the cut-off value, below which a suboptimal postoperative regression in pulmonary hypertension and FTR is predicted. CONCLUSIONS: An in-vivo EOAI <1.19 cm2/m2 strongly suggests a suboptimal hemodynamic recovery following MVR with the bileaflet mechanical prosthesis used in the present study. Although no direct relationship between prosthesis size and in vivo EOAI was demonstrated, the logical approach is to implant a prosthesis of the largest possible size.

Successful treatment of phlegmasia cerulea dolens in a nonagenarian patient with chronic iliac vein occlusion using a Cleaner thrombectomy device.

A 91-year-old man was admitted to the emergency room with a 3-day history of severe pain, swelling and cyanosis in his left leg. Duplex ultrasound findings were suggestive of acute left popliteal and iliofemoral venous thrombosis. Heparin was initiated and pharmacomechanical thrombolysis (PMT) was performed with the use of a Cleaner thrombectomy device. At the completion of PMT, repeat venography revealed chronic proximal iliac vein occlusion. After the procedure, alteplase was infused via the intra-arterial catheter at a rate of 0.5 mg/h over 24 h to clear the thrombus distal to the popliteal vein and residual thrombus. The patient's signs and symptoms improved markedly after the intervention. There were no minor or systemic bleeding problems. He was discharged home 10 days after the procedure without any complications.

Remote Targets for Right Coronary Artery Bypass: Distal Trunk or Posterior Descending Artery Grafting.

BACKGROUND: Choosing a good anastomotic site is crucial during surgical revascularization of the right coronary artery (RCA) system. In many instances of distal and/or sequential main trunk disease, either the right posterior descending coronary artery (RPDA) or distal part of the right main coronary artery (DRCA) is preferred as the target vessel. In this article, the saphenous vein graft (SVG) patency is compared between these two main targets in the long term. MATERIALS AND METHODS: Postoperative control coronary angiograms were obtained and assessed from 452 patients undergoing conventional on-pump coronary artery bypass grafting with either a DRCA (n = 305) or a RPDA graft (n = 147) after an average postoperative period of 5.8 ± 4.3 years (range: 2 months-20 years; a total of 2,627 patient-years). RESULTS: The overall graft patency was 60%. The 15-year patency rate was better for the DRCA grafts than that for the RPDA grafts (32 ± 5% vs. 19 ± 6%, respectively; p = 0.001), irrespective of target vessel caliber. Other factors adversely influencing the long-term graft patency were poor target vessel quality (p = 0.002) and hypercholesterolemia (p = 0.01). On the other hand, target vessel diameter, diabetes mellitus, hypertension, chronic renal insufficiency, obesity, peripheral arterial disease, or SVG quality were not associated with poor long-term graft patency in these patients having distal-type RCA disease. CONCLUSIONS: In the presence of distal and/or sequential right coronary disease, DRCA may be the target vessel of choice for bypass grafting, rather than the RPDA, mainly for better long-term SVG patency rates in this location.