Early Mortality Predictors in İnfective Endocarditis Patients: A Single-Center Surgical Experience

ABSTRACT Introduction: Infective endocarditis is a disease that progresses with morbidity and mortality, afecting 3-10 out of 100,000 people per year. We conducted this study to review the early outcomes of surgical treatment of infective endocarditis. Methods: In this retrospective study, 122 patients who underwent cardiac surgery for infective endocarditis in our clinic between November 2009 and December 2020 were evaluated. Patients were divided into two groups according to in-hospital mortality. Demographic, echocardiographic, laboratory, operative, and postoperative data of the groups were compared. Results: Between November 3, 2009, and December 7, 2020, 122 patients were operated for infective endocarditis in our hospital. Emergency surgery was performed in nine (7.3%) patients. In-hospital mortality occurred in 23 (18.9%) patients, and 99 (81.1%) patients were discharged. In-hospital mortality was related with older age, presence of periannular abscess, New York Heart Association class 3 or 4 symptoms, low albumin level, high alanine aminotransferase level, and longer cross-clamping time (P<0.05 for all). Conclusion: The presence of paravalvular abscess was the most important prognostic factor in patients operated for infective endocarditis.

Early Mortality Predictors in Infective Endocarditis Patients: A Single-Center Surgical Experience.

INTRODUCTION: Infective endocarditis is a disease that progresses with morbidity and mortality, afecting 3-10 out of 100,000 people per year. We conducted this study to review the early outcomes of surgical treatment of infective endocarditis. METHODS: In this retrospective study, 122 patients who underwent cardiac surgery for infective endocarditis in our clinic between November 2009 and December 2020 were evaluated. Patients were divided into two groups according to in-hospital mortality. Demographic, echocardiographic, laboratory, operative, and postoperative data of the groups were compared. RESULTS: Between November 3, 2009, and December 7, 2020, 122 patients were operated for infective endocarditis in our hospital. Emergency surgery was performed in nine (7.3%) patients. In-hospital mortality occurred in 23 (18.9%) patients, and 99 (81.1%) patients were discharged. In-hospital mortality was related with older age, presence of periannular abscess, New York Heart Association class 3 or 4 symptoms, low albumin level, high alanine aminotransferase level, and longer cross-clamping time (P<0.05 for all). CONCLUSION: The presence of paravalvular abscess was the most important prognostic factor in patients operated for infective endocarditis.

Outcomes of COVID-19 infection occurring in the recovery period of the open-heart surgery.

Background: In this study, we aimed to examine the effect of novel coronavirus 2019 disease (COVID-19) on the healing process of patients undergoing open-heart surgery. Methods: Between October 2020 and May 2021, a total of in 22 patients (14 males, 8 females; mean age: 60±15 years; range, 18 to 82 years) who developed COVID-19 within the first 30 days after open-heart surgery were retrospectively analyzed. Since the study was conducted in the pre-vaccination period, all of the patients were unvaccinated. Demographic, operative, and laboratory data of the patients were analyzed, and morbidity and mortality rates were evaluated. Results: Postoperative COVID-19 infection occurred in 22 of 1,171 patients who underwent open-heart surgery. Pneumonia developed in 14 (64%) patients and mechanical ventilation support was required in 50% (n=7) of them. Mortality was seen in eight (36%) patients. Only procalcitonin level (p=0.003) and age (p=0.005) had significant effects on survival. Conclusion: Postoperative COVID-19 infection is associated with high pneumonia and mortality rates in unvaccinated patients. Protocols that can prevent false polymerase chain reaction negativity and early contamination can be life-saving.

Aortic floating thrombi with lower limb ischemia and renal infarct in COVID-19: A remote thromboembolic complication.

As the COVID-19 pandemic continues, its novel complications are being increasingly recognized, and new mechanisms of the disease are being unraveled. Aortic free-floating thrombus is exceptionally rare, and prompt diagnosis is vital to alleviate its detrimental end organ effects. We present a patient who was previously discharged owing to COVID-19 pneumonia, admitted with acute onset of lower limb pain, and was diagnosed with aortic free-floating thrombus ended up with embolic events. Clinicians should be aware of COVID-19-related thromboembolic complications, and close monitoring of patients with risk factors is vital for a timely and accurate diagnosis and management.

Mediastinitis after cardiac surgery: risk factors and our vacuum-assisted closure results.

INTRODUCTION: Mediastinitis after cardiac surgery is a rare complication, but with high morbidity and mortality. AIM: To determine its risk factors and to investigate the efficacy of vacuum-assisted closure (VAC). MATERIAL AND METHODS: Nine thousand one hundred sixty cases of patients who underwent cardiac surgery during 2010-2017 were reviewed retrospectively. One hundred and twenty-seven patients, the case group, were treated by VAC. Three hundred cases with no diagnosis of mediastinitis were selected as the control group. Both groups' clinical and demographic characteristics, preoperative variables, and postoperative follow-up parameters were compared. Factors affecting treatment were analyzed. RESULTS: We found that the presence of diabetes mellitus, bilateral internal thoracic artery and intra-aortic balloon pump usage are independent risk factors for the development of mediastinitis (p < 0.05). It was found that 74% of tissue cultures were positive and the most common detected organism was Staphylococcus. It was found that many perioperative parameters had a significant effect on the duration of treatment (p < 0.05). However, regression analysis revealed that bacterial growth was the only independent variable in prolonging the treatment period. CONCLUSIONS: We believe that the establishment of perioperative blood glucose regulation, patient selection to use bilateral internal thoracic artery grafts, and maximum attention to sepsis and antisepsis rules in patients who need mechanical support devices such as intra-aortic balloon pump, will significantly reduce the development of mediastinitis. Since we could not find an independent risk factor for the duration of VAC treatment other than culture growth, we think that VAC therapy is successful and safe in the treatment of mediastinitis and should be used more widely.

Effect of Pulsatile Cardiopulmonary Bypass in Adult Heart Surgery.

BACKGROUND: This study aimed to examine the effect of pulsatile flow pattern on tissue perfusion, particularly cerebral tissue perfusion, at pre-determined intervals during CPB, as well as its effects on postoperative morbidity and mortality. METHODS: This retrospective study included 134 adult patients, who underwent cardiac surgery with cardiopulmonary bypass (CPB). Patients were grouped based on the flow pattern used during CPB: non-pulsatile CPB group (N = 82) and pulsatile CPB group (N = 52). Cerebral oxygen saturation, arterial pH and arterial lactate levels were measured at four time points, during the operation and the 2 groups were compared with regard to changes over time as well as differences in postoperative outcomes. RESULTS: The 2 groups were similar, in terms of mean values and intraoperative changes in cerebral oxygen saturation and arterial pH. Non-pulsatile CABG group had significantly higher arterial lactate levels over the measurement period, which was not affected by the timing of the measurements. Postoperative drainage, duration of ventilation and duration of hospital stay significantly were higher and postoperative blood urea nitrogen significantly was lower in the non-pulsatile CPB group. Other postoperative outcomes were similar across the groups. CONCLUSION: Findings of this study do not support the superiority of pulsatile flow pattern during CPB, in terms of cerebral oxygen saturation or postoperative mortality/morbidity. Further and larger comparative studies are warranted before pulsatile blood flow pattern can be established as a routine clinical method.

The Prevalence of Periodontal Pathogenic Bacteria in Atherosclerotic Cardiovascular Disease.

BACKGROUND: A possible link between periodontal pathogenic bacteria and atherosclerosis may exist based on the inflammatory mechanisms initiated by bacteria found in periodontal lesions. Our aim was to investigate the presence of DNA originating from T. denticola, C. rectus, T. forsythia, and P. gingivalis in the vascular tissue specimens obtained from patients who underwent surgery for arteriosclerotic vascular disease in this study. METHODS: A total of 96 patients diagnosed with valvular heart disease due to atherosclerosis and 85 patients with advanced aortic valve stenosis due to rheumatic fever and had undergone aortic valve replacement were included as the study (PG) and the control groups (CG), respectively. Atheroma plaques and vascular tissue specimens were collected from PG and CG during cardiovascular surgical procedures. Revitalization of the lyophilized T. denticola, ATCC 35405; C. rectus, ATCC 33238; P. gingivalis, ATCC 33277 and T. forsythia, ATCC 43037 strains was performed according to the manufacturer's instructions. C. rectus, T. forsythia, and T. denticola DNA samples were analyzed using the one-step in-house PCR method. RESULTS: In one (1.04%) and three (3.13%) out of 96 atherosclerotic PG tissue specimens, P. gingivalis and T. for-sythia DNA were detected, respectively. No T. denticola or C. rectus DNA was found in the study specimens. Periodontal pathogenic bacteria were not observed in 85 CG tissue specimens. There was no statistically significant difference between PG and CG for the presence of P. gingivalis and T. forsythia DNA using Fischer's Exact test (p > 0.05). CONCLUSIONS: In conclusion, with the case-control studies on a small scale such as in our study, it is not possible to determine a causality relationship between periodontal pathogenic bacteria and formation of atherosclerosis. Periodontal pathogenic bacteria may not be the only factor that causes inflammatory diseases associated with atherosclerosis. Host response and inflammatory mechanisms may be affected by other factors such as ethnicity, dietary habits, nutritional availability, and lifestyle. Taken together, it is difficult to conclude a causal link between periodontal pathogenic bacteria and formation of atherosclerosis.

Right pericardial window opening: a method of preventing pericardial effusion.

AIM: In this study, we aimed to investigate the superiority of right pericardial window (RPW) versus posterior pericardial drain placing for the parameters of pericardial effusion and the postoperative complications at the patients who has undergone cardiac surgery. MATERIALS AND METHODS: Between July and September 2018, 120 adult patients (mean age 50.30 ± 14.61) who underwent cardiac surgery without the necessity of opening the pleura were included in the study. In Group 1, the RPW was opened (n = 60), and Group 2 posterior pericardial drainage tube was placed without RPW (n = 60). Risk factors and postoperative complication were evaluated and compared between the Groups. RESULTS: Cardiac tamponade occurrence was not significantly different between the Groups (Group 1, n = 0 and Group 2, n = 3, p = 0.079). Postoperative transthoracic echocardiographic controls revealed significant pericardial effusion in Group 2 (6.90 mm ± 13.02 mm) compared to Group 1 (2.30 mm ± 5.60 mm) (p = 0.013). Postoperative creatinine levels were 0.75 ± 0.26 in Group 1 and 0.88 ± 0.36 in Group 2 (p = 0.022). A significant decrease in glomerular filtration rate was observed in Group 2 (102.7 ± 24.5 and 91.2 ± 28, p = 0.019). Postoperative acute renal failure was significantly higher in Group 2 compared to Group 1 (p < 0.001). Postoperative new onset atrial fibrillation occurred in 4 patients in Group 1 and 8 in Group 2 (p = 0.224). The duration of intensive care unit stay was 36.00 ± 22.31 h in Group 1 and 53.60 ± 59.50 h in Group 2 (p = 0.034). Development of pneumothorax, pneumonia and pleural effusion were not statistically different between the Groups (p = 0.079, 0.171, 0.509). CONCLUSION: RPW application is more effective on preventing postoperative complications in cardiac surgery instead of placing drains in posterior pericardium.

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.

Rapidly Progressive Malignant Fibrous Histiocytoma of Right Atrium: a Rare Case Report.

We are going to present a case of malignant fibrous histiocytoma in the right atrium, which is a very rare entity. The patient had a right atrial mass, which prolapsed through the tricuspid valve into the right ventricle, causing functional tricuspid valve stenosis. The tumor was completely resected and the patient had an uneventful postoperative period. Histopathological examination reported malignant fibrous histiocytoma. The patient presented to the emergency department five weeks after discharge with dyspnea and palpitation. Echocardiography and magnetic resonance imaging revealed recurrent right atrial tumor mass. His clinical status has worsened, with syncope and acute renal failure. On the repeated echocardiography, suspected tumor recurrence was observed in left atrium, which probably caused systemic embolization. Considering the aggressive nature of the tumor and systemic involvement, our Heart Council decided to provide palliative treatment by nonsurgical management. His status deteriorated for the next few days and the patient succumbed to a cardiac arrest on the 4th day.

The role of the angle of the ascending aortic curvature on the development of type A aortic dissection: ascending aortic angulation and dissection.

OBJECTIVES: Type A aortic dissection (TAD), which consists of an intimal tear in the aorta, necessitates emergency surgery. Various risk factors related to aortic dissection have been defined in the literature. According to our hypothesis, a narrower angle of ascending aortic curvature (AAAC) may be an additional risk factor in relation to aortic dissection due to the increased force applied to the aortic wall. METHODS: Patients undergoing ascending aortic surgery due to an ascending aortic aneurysm (AsAA) (n = 105) and patients undergoing such surgery because of the occurrence of TAD (n = 101) were enrolled in this study. The AAAC was measured using Cobb's method; the measurements were made on all patients by just 1 cardiovascular radiologist using 3-dimensional computerized tomographic imaging. This measurement was made indirectly by using the aortic valve and brachiocephalic artery to avoid obtaining misleading data as a result of distortions due to dissection. A statistical comparison was also performed relating the traditional risk factors for TAD to other clinical and echocardiographic parameters: the diameter of the ascending aorta and the AAAC. RESULTS: The AAAC was found to be narrower statistically in the TAD group (α = 76.2° ± 17.5°) than it was in the AsAA group (α = 92.9° ± 13°) (P < 0.001). Furthermore, mean ascending aortic diameter (P = 0.019), the presence of a bicuspid aorta (P = 0.007) and aortic valve stenosis (P = 0.005) were higher in the AsAA group. According to multivariable analyses, a narrower AAAC is a significant predictor for the development of TAD (odds ratio 0.93, 95% confidence interval 0.91-0.95; P < 0.001). Overall hospital mortality from various causes including stroke, myocardial infarction, bleeding or renal failure was 13% in the TAD group and 7% in the AsAA group. CONCLUSIONS: According to this study, the AAAC was significantly smaller in aortic dissection patients than in aortic aneurysm patients. This may be related to higher shear stress and elevated pressure on the ascending aorta in patients with a narrower AAAC. Thus, a narrower AAAC may be an additional risk factor in the development of TAD. Therefore, we may need to be more careful in terms of looking for the development of aortic dissection in patients with narrower AAAC.

Rapidly progressive malignant fibrous histiocytoma of right atrium: a rare case report

Abstract We are going to present a case of malignant fibrous histiocytoma in the right atrium, which is a very rare entity. The patient had a right atrial mass, which prolapsed through the tricuspid valve into the right ventricle, causing functional tricuspid valve stenosis. The tumor was completely resected and the patient had an uneventful postoperative period. Histopathological examination reported malignant fibrous histiocytoma. The patient presented to the emergency department five weeks after discharge with dyspnea and palpitation. Echocardiography and magnetic resonance imaging revealed recurrent right atrial tumor mass. His clinical status has worsened, with syncope and acute renal failure. On the repeated echocardiography, suspected tumor recurrence was observed in left atrium, which probably caused systemic embolization. Considering the aggressive nature of the tumor and systemic involvement, our Heart Council decided to provide palliative treatment by nonsurgical management. His status deteriorated for the next few days and the patient succumbed to a cardiac arrest on the 4th day.

Left ventricular assist device implantation combined with bentall procedure

Abstract Ventricular assist devices (VADs) are an important technological development for patients with end-stage heart failure, and approximately 50% of these patients require various additional cardiac procedures. Here we presente the case of a patient suffering from severe aortic insufficiency, aortic root dilatation, and an ascending aortic aneurysm with end-stage decompensated heart failure. We performed the Bentall procedure combined with a left VAD implantation during the same session. The postoperative period was uneventful for this patient, and he was discharged on the 32nd postoperative day. The heart failure symptoms of the patient are reasonable, and he is still on the heart transplantation waiting list.

Left Ventricular Assist Device Implantation Combined with Bentall Procedure.

Ventricular assist devices (VADs) are an important technological development for patients with end-stage heart failure, and approximately 50% of these patients require various additional cardiac procedures. Here we presente the case of a patient suffering from severe aortic insufficiency, aortic root dilatation, and an ascending aortic aneurysm with end-stage decompensated heart failure. We performed the Bentall procedure combined with a left VAD implantation during the same session. The postoperative period was uneventful for this patient, and he was discharged on the 32nd postoperative day. The heart failure symptoms of the patient are reasonable, and he is still on the heart transplantation waiting list.

A Study Demonstrating the Quantitative Relationship Between Internal Thoracic Artery Length and Free Flow.

BACKGROUND: The left internal thoracic artery (LITA) is the most commonly used arterial bypass conduit in coronary artery bypass graft (CABG) patients and inadequate LITA flow can result in an increase in morbidity and mortality. In this study, we evaluated the effect of excision of the distal spasmodic segment of the LITA on the free flow in CABG patients. METHODS: This study consisted of 47 patients who underwent elective CABG performed with or without other cardiac surgery, between July 2015 and December 2015. Excised LITA length was shorter than 15mm in group 1, between 15mm and 30mm in group 2 and longer than 30mm in group 3. Left ITA free flow was measured for 60seconds into a container before and after the distal LITA excision. The inter-measurement differences were calculated for the three groups. Thereafter, the comparison was performed in terms of free flow difference amongst the three groups. RESULTS: The mean difference of LITA free flow was 27.6±22.7ml/minute in group 1, 35.4±26.7ml/minute in group 2, and 52.6±26.1ml/minute in group 3. There were significant differences in terms of free flow difference between the groups (p=0.008). Also, differences were statistically significant in group 1 versus group 3 (p=0.003) and group 2 versus group 3 (p=0.038) in the intergroup comparisons. CONCLUSIONS: The distal part of the LITA has more spasmodic potential than other segments. This spasm may result in low flow of LITA grafts. Therefore, an as long as possible excision of the distal LITA segment may be required to avoid the spasmodic effect.

Effect of vitamin D deficiency on the development of postoperative atrial fibrillation in coronary artery bypass patients.

Introduction: Various factors may be responsible for the development of postoperative atrial fibrillation (POAF) in coronary artery bypass graft (CABG) patients. In our study, we demonstrated the effect of vitamin D deficiency on the development of POAF. Methods: In this prospective case control study, patients undergoing elective, isolated CABG were considered. A total of 15 patients (16.6%) who developed POAF during the first five days after surgery made up the POAF group. Seventy-five patients that had a sinus rhythm in the same period were the non-POAF group. The two groups were compared statistically in terms of laboratory, clinical, echocardiographic, operative, and postoperative parameters. Results: All patients were in sinus rhythm at discharge. The baseline characteristics of the study groups were comparable. The POAF group had a lower vitamin D level than the non-POAF group (9.0 ± 5.0 and 15.0 ± 8.4 ng/mL, respectively; P=0.007). In the POAF group, the patients' left atrium diameter and incidence of hypertension (HT) were higher than those of the non-POAF group. Conclusion: Incidence of POAF was significantly higher in patients with vitamin D deficiency or insufficiency than the patients with vitamin D level in normal range. Therefore vitamin D deficiency or insufficiency may be a predictor of POAF in patients with CABG.

Comparison of periprocedural and long term outcomes of proximal versus distal cerebral protection method during carotid artery stenting.

BACKGROUND: The aim of this study was to assess the periprocedural and one-year outcomes of two different cerebral protection systems used during carotid artery stenting (CAS). PATIENTS AND METHODS: We enrolled 90 consecutive patients with carotid artery stenosis who underwent CAS with a proximal flow blockage protection system (mean age 69.7 ± 8) or distal protection with a filter (mean age 70.8 ± 7). RESULTS: CAS was performed successively on 89 patients (99 %). Adverse events were defined as major stroke, minor stroke, transient ischemic attack (TIA), myocardial infarction, and death. Two strokes, one TIA, one death, and one myocardial infarction were observed in-hospital. There were no significant differences in safety or benefits between the proximal flow blockage embolic protection system (n = 45) and the distal filter protection system (n = 45) in terms of clinically apparent cerebral embolism, TIA, death, or myocardial infarction during the periprocedural stage or during the one-year follow-up period. CONCLUSIONS: Although it has been shown that the proximal flow blockage cerebral protection system decreases the risk of silent cerebral embolism, it has no advantage over the distal filter protection system in terms of adverse cerebrovascular or cardiac events during the periprocedural stage or during the long-term follow-up period.

Short-term effects of transcatheter aortic valve implantation on left atrial appendage function.

BACKGROUND: The beneficial effects of the transcatheter aortic valve implantation (TAVI) on echocardiographic parameters including left atrial (LA) and left ventricular (LV) functions were described by previous studies. The aim of this study was to analyze the effects of TAVI on left atrial appendage (LAA) function assessed by transthoracic and transesophageal echocar-diography. METHODS: Fifty-five patients with severe symptomatic aortic stenosis were included in this prospective study. LAA early and late emptying velocities, LAA filling velocity, peak early diastolic (EM), late diastolic (AM), and systolic (SM) velocities were measured with pulsed wave Doppler and tissue Doppler imaging, and E/Em ratio was calculated before and 7.1 ± 2.8 days after TAVI. A subgroup analysis was performed in accordance with the left ventricular ejection fraction (LVEF) of the patients and the severity of their LV diastolic dysfunction. RESULTS: Although the post-procedure peaks and mean gradients of the patients decreased sig-nificantly, the LVEF increased significantly in those who had low LVEF before the procedure. The post-procedure E/Em ratio decreased significantly (p < 0.001). The post-procedural LAA mean filling velocity and EM velocity were significantly higher than the pre-procedural filling velocity (p < 0.001, p = 0.002, respectively). In the subgroup analysis, the post-procedural LAA filling velocity, early and late LAA emptying velocities, in addition to the mean velocity of the EM, AM, and SM were significantly higher than before the procedure in patients with LVEF of < 50% and E/Em ratios of > 15. CONCLUSIONS: LAA function improved soon after the TAVI procedure, especially in patients with low LVEF and marked LV diastolic dysfunction.

The role of Porphyromonas gingivalis in the development of atherosclerosis and its relationship with fim A genotype.

BACKGROUND: Porphyromonas gingivalis, a major periodontal pathogen, is gaining increasing attention for its possible association with atherosclerosis. Its fimbriae are classified into six genotypes (Types I-V, Ib) based on the diversity of the fim A genes encoding the fimbrial subunits. In this study, fim A genotype's distribution of P. gingivalis was analyzed in atherosclerotic plaque specimens. METHODS: A total of 50 atherosclerotic plaque specimens and 50 non-atherosclerotic, post stenotic aneurysm specimens were collected from patients undergoing cardiovascular surgery. Bacterial DNA was also extracted from each specimen, as real-time PCR was carried out with P. gingivalis-specific primer sets. The positive specimens of P. gingivalis were further analyzed to discriminate the fim A genotype using real-time and nested PCR methods. RESULTS: P. gingivalis was detected only in one atherosclerotic plaque; however, the genotype was nontypable in this specimen. CONCLUSIONS: We state that it is not easy to show a significant relationship between P. gingivalis, its fim A genotype, and atherosclerosis. We suggest that new extended studies based especially upon the quantitave determination of P. gingivalis and its genotype distribution on atherosclerotic specimens are needed to show an evident relationship between atherosclerosis and P. gingivalis.