Combined treatment with endovenous laser ablation and compression therapy of incompetent perforating veins for treatment of recalcitrant venous ulcers.

Objective Patients with healed venous ulcers often experience recurrence of ulceration, despite the use of long-term compression therapy. This study examines the effect of closing incompetent perforating veins (IPVs) on ulcer recurrence rates in patients with progressive lipodermatosclerosis and impending ulceration. Methods Patients with nonhealing venous ulcers of >2 months' duration underwent duplex ultrasound to assess their lower extremity venous system for incompetence of superficial, perforating, and deep veins. Endovenous laser ablation (EVLA) of perforating veins was performed on patients with CEAP 6 disease with increasing hyperpigmentation, lipodermatosclerosis, and/or progressive malleolar pain. A minimum of 2 months of compressive therapy was attempted before endovenous ablation of IPVs. Demographic data, risk factors, CEAP classification, procedural details, and postoperative status were all recorded. Results Forty ulcers with 46 associated IPVs were treated with EVLA in 36 patients with CEAP 6 recalcitrant venous ulcers. Treated incompetent perforator veins were located in the medial ankle (85.7%), calf (10.7%), and lateral ankle (3.5%). Endovenous laser ablation was successful in 76% (35/46) with the first laser treatment of incompetent perforator veins and 15.2% (7/46) additional ablation procedures were performed. Of the 46 treated IPVs, 42 (91.3%) were occluded on the duplex examination at 12 months. The average energy administrated per perforating vein treated was 162 joule. Two patients reported localized paresthesia, which subsided spontaneously, but no deep venous thrombosis or skin burn was observed. Conclusion Especially in the case of liposclerotic or ulcerated skin in the affected region, PAP of IPVs is highly effective, safe, and appears to be feasible. Patients with active venous ulcers appear to benefit from EVLA of incompetent perforators in order to reduce the risk of ulcer recurrence.

Biodegradable annuloplasty ring two years after implantation: first histological demonstration in human mitral annulus.

Although biodegradable annuloplasty rings have been used in clinics for almost a decade for mitral and/or tricuspid annuloplasty, the fate of the ring at the histological level has not been demonstrated in humans to date. The mitral annulus of a 39-year-old patient who underwent heart transplantation almost two years after annuloplasty was subjected to histological evaluation to demonstrate the mitral annular structures and consequences of biodegradable ring annuloplasty. On examination, the ring was shown to have completely degraded, and a fibrous band had formed in the posterior mitral annulus. No signs of residual calcification were observed. Neighboring structures such as circumflex artery and the great cardiac vein were intact. It can be concluded that the biodegradable annuloplasty ring is completely degraded in humans after implantation, leaving a fibrous band behind to support the posterior annulus. The risk of circumflex artery and great cardiac vein injury may not be considerable if the correct implantation technique is used.

Design of a centrifugal blood pump: Heart Turcica Centrifugal.

A prototype of a new implantable centrifugal blood pump system named Heart Turcica Centrifugal (HTC) was developed as a left ventricular assist device (LVAD) for the treatment of end-stage cardiac failure. In the development of HTC, effects of blade height and volute tongue profiles on the hydraulic and hemolytic performances of the pump were investigated. As a result, the prototype was manufactured using the best blade height and volute tongue profiles. Performance of the prototype model was experimentally evaluated in a closed-loop flow system using water as the medium. The hydraulic performance requirement of an LVAD (5 L/min flow rate against a pressure difference of 100 mm Hg) was attained at 2800 rpm rotational speed.

Fate of vena saphena magna stump after endovenous laser ablation with 980-nm diode laser: 12-month follow-up.

OBJECTIVE: The aim of this study was to investigate the fate of VSM stump and its relation to the incidence of thrombosis during a-12 mo follow-up. BACKGROUND DATA: Varicose veins are a common problem. There are several treatment alternatives available. Conventional surgical treatment is associated with high recurrence and complications. However, with the recent development of minimal invasive surgery, various techniques have been developed. Endovenous laser ablation (EVLA) is one of these techniques, which has proven to be safe and effective. Since EVLA is safe and has minor adverse reactions, residual VSM stump and its association with thrombosis after EVLA has not been well studied in literature. MATERIALS AND METHODS: Sixty-nine patients underwent EVLA with a 980-nm diode laser (Ceralas D, Biolitec AG, Jena, Germany), and retrospectively obtained data were analyzed over a 12-mo period. Twenty-six patients were excluded due to the lack of follow-up. All EVLA procedures were performed by the same surgeon, who has experience of EVLA. Laser power was set at 10-15 W depending on the size of targeted vein. The saphenous vein was percutaneously punctured with an 18-gauge needle under ultrasonography guidance. Patients were reassessed at 1 wk, and at 3, 6, and 12 mo after the procedure. RESULTS: Technical success was accomplished in all patients. One patient had flow signals with patent segment of the VSM visualized by venous duplex ultrasonography at 1 mo, which persisted until the 12-mo follow-up. None of the patients developed acute deep-venous thrombosis. CONCLUSIONS: The present study shows that residual VSM stump-length measurement differences at 7 d and 12 mo were statistically significant. In future, large-scale studies are needed, focusing on the proper position of the catheter tip to the saphenofemoral junction and timing the intervals of follow-up after EVLA.

First Turkish experiences of assisted beating-heart coronary artery bypass graft with the Impella Microaxial Ventricular Assist Device.

The importance of minimally invasive cardiac operations, performed off-pump, without the support of cardiopulmonary bypass (CPB), is continuously increasing. Complete revascularization of obstructed coronary arteries is needed to obtain a better long-term outcome. Insertion into the left ventricle of an efficient microaxial pump can be useful when targeting an important coronary artery located at posterior wall of the heart in a patient with hemodynamic deficiency. The use of such a device can enable surgeons to avoid conversion from a preplanned off-pump strategy to traditional on-pump coronary bypass surgery. The Impella Microaxial Ventricular Assist Device (VAD) (Abiomed, Aachen, Germany) is a miniature pump with a 7-mm catheter and a flow rate of approximately 2.5-5 L/min. This device can enable cardiovascular surgery to be performed without damaging the left ventricle and causing serious aortic deficiency. Therefore, in patients with serious comorbidity, complete revascularization may be performed off pump, with the heart beating, because of the hemodynamic stability provided with the support of the microaxial intracardiac pump. If required, this pump can also support the heart during the early postoperative period. We report the first assisted beating-heart coronary artery bypass graft surgery performed with the Impella Microaxial VAD in our country. The surgery was performed on 2 patients considered high risk on the basis of EUROSCORE testing.

Effects of single-dose gabapentin on postoperative pain and morphine consumption after cardiac surgery.

OBJECTIVE: The purpose of this study was to evaluate the analgesic effect of single-dose preoperative gabapentin on postoperative pain and morphine consumption after cardiac surgery. DESIGN: A randomized, double-blind, placebo-controlled, clinical study. SETTING: A single university hospital. PARTICIPANTS: Sixty patients undergoing coronary artery bypass graft surgery. INTERVENTIONS: Patients were randomly allocated into 2 groups preoperatively either to receive 600 mg of oral gabapentin (GABA) or placebo (PLA) 2 hours before the operation. After extubation, an anesthesiologist blinded to the groups recorded pain scores both at rest and with cough with a 10-point verbal rating scale and sedation scores at 2, 6, 12, 18, 24, and 48 hours. Cumulative morphine consumption and the incidence of side effects were recorded during the study period. MEASUREMENTS AND MAIN RESULTS: The total morphine consumption was lower in the GABA group (6.7 ± 2.5 mg) than in the PLA group (15.5 ± 4.6 mg, p < 0.01). Pain scores at rest were significantly lower in the GABA group than in the PLA group throughout the study period (p < 0.05 in all measurement times). Pain scores at 2, 6, and 12 hours during coughing were significantly lower in the GABA group (p < 0.05). The number of oversedated patients was significantly higher in the GABA group at 2, 6, and 12 hours of study compared with PLA (p < 0.001 at 2 and 6 hours and p < 0.02 at 12 hours). The postoperative mechanical ventilation period was significantly prolonged in the GABA group (6.6 ± 1.2 hours) compared with the PLA group (5.5 ± 1 hours, p < 0.01). Nausea incidence was significantly lower in the GABA group (n = 9) than in the PLA group (n = 18, p = 0.02). CONCLUSIONS: Oral GABA at a dose of 600 mg given before cardiac surgery significantly reduced postoperative morphine consumption and postoperative pain both at rest and with cough.

High-risk left main coronary artery bypass surgery supported by the Impella Recover LP 2.5 assist device: an alternative insertion technique.

Patients with high-risk coronary lesions such as left main stenosis and a severely depressed left ventricular ejection fraction are at risk of death and morbidity-related complications during coronary artery bypass surgery. Several alternative methods have been developed for managing this problem, but it is still challenging, even for highly experienced and well-equipped cardiac surgery centers. We report the case of a successful coronary artery bypass surgery supported by the Impella Recover LP 2.5 assist device and using an alternative insertion technique for the ascending aorta in a patient with high-risk coronary lesions, such as left main disease.

Surgical treatment of a bronchial cyst causing compression to the left atrium and pulmonary artery.

Bronchogenic cysts that formed during the development of the tracheobronchial tree in the gestational period are mostly asymptomatic until adulthood. Cysts localized in the middle mediastinum, specifically in the subcarinal region, on the other hand, may cause serious symptoms by compressing the heart and major vessels due to their close proximity. In this report it is suggested that surgical resection of a giant bronchogenic cyst that compresses the heart and great vessels should be securely performed in the presence of a readily available cardiopulmonary bypass capability.

Giant hydatid cyst of the interventricular septum mimicking acute myocardial infarction on ECG: an unusual cause of ST segment elevation.

Hydatid disease is a parasitic infection caused by larvae of Echinococcus granulosus, which is still endemic in many cattle-raising areas. Cardiac involvement is a rare, but potentially a very serious complication of the hydatid disease. The diagnosis of cardiac cyst hydatid may be difficult due to the nonspecific symptoms and varying clinical presentations. With this report, we describe a case of giant hydatic cyst of the interventricular septum that caused ischemic changes on ECG, mimicking acute myocardial infarction. The final diagnosis was made by combining echocardiography, MRI, and serological tests. Surgical resection of the cyst, followed by albendezol treatment yielded a favorable outcome.

Pulsatile flow improves renal function in high-risk cardiac operations.

The effects of pulsatile perfusion on microcirculation and renal function in high-risk patients were evaluated in this study. Pulsatile roller pumps with a pulsatile control module and membrane oxygenator were used in a clinical setting. 40 patients undergoing elective cardiac surgery with a high risk of either having chronically obstructive pulmonary disease or chronic renal failure were randomly included in the study to be perfused using pulsatile or continuous flows. Blood samples were collected at induction of anesthesia, at the time of aortic clamping and declamping and 1 and 24 h following cessation of the bypass. Urea and creatinine concentrations in blood were measured and systemic vascular resistance was calculated. Urine output, crystalloid and colloid infusions were recorded. We observed that pulsatile roller pump perfusion and the extracorporeal circuit used in the clinical study improved microcirculation and renal function in high-risk patients undergoing cardiopulmonary bypass.

Risk factors for stroke following coronary artery bypass operations.

BACKGROUND: Although the overall complication rates have been decreased significantly in recent years, stroke rates still remain high in patients undergoing coronary bypass operations. This study is designed to evaluate the risk factors for stroke in patients who had undergone coronary artery bypass surgery in an 8-year period in our clinic. METHODS: Between 1995 and 2003, 8547 coronary artery operations under cardiopulmonary bypass were performed. Retrospective analysis of the patient files revealed that 75 (0.9%) patients had stroke in the early postoperative period. RESULTS: Mean age of these patients was 62.3 +/- 9.5 years, and 54 (72%) were males. Stroke rate was 1.2% between 1995 and 1998 and this was significantly higher from the stroke rate (0.7%) of the period 1998 to 2003 (p = 0.03). Major technical differences between these two periods were the routine application of preoperative carotid arteries Doppler evaluation and intraoperative epiaortic echocardiography after 1998. Higher age (p = 0.000), female sex (p = 0.005), smoking (p = 0.03), presence of diabetes mellitus (p = 0.01), hypertension (p = 0.008), and left main coronary artery disease (p = 0.001), carotid surgery (p = 0.000), and peripheral vascular disease (p = 0.049) were identified as important risk factors in univariate analysis for stroke development. Higher age (p = 0.000; OR = 21.38), left main coronary artery disease (p = 0.007; OR = 7.26), peripheral vascular disease (p = 0.050; OR = 3.08), and operation date before 1998 (p = 0.012; OR = 6.33) were identified as important risk factors in logistic regression analysis. According to intraoperative epiaortic ultrasonography, operative strategy was changed in 9% of patients. Thirty-seven (49.3%) of the stroke patients died. Female sex (p = 0.023; OR = 5.18) and preoperative hypertension (p = 0.045; OR = 4.03) were observed as significant risk factors for mortality after stroke. CONCLUSION: Development of stroke is one of the major reasons of mortality after coronary artery bypass operations. It is essential to take all the measures to prevent this complication, especially in patients with known risk factors. Evaluation of carotid arteries prior to operation and application of routine intraoperative epiaortic echocardiography may in part eliminate stroke.