Microcirculatory Response to Blood vs. Crystalloid Cardioplegia During Coronary Artery Bypass Grafting With Cardiopulmonary Bypass.

Background: Blood cardioplegia attenuates cardiopulmonary bypass (CPB)-induced systemic inflammatory response in patients undergoing cardiac surgery, which may favorably influence the microvascular system in this cohort. The aim of this study was to investigate whether blood cardioplegia would offer advantages over crystalloid cardioplegia in the preservation of microcirculation in patients undergoing coronary artery bypass grafting (CABG) with CPB. Methods: In this prospective observational cohort study, 20 patients who received crystalloid (n = 10) or blood cardioplegia (n = 10) were analyzed. The microcirculatory measurements were obtained sublingually using incident dark-field imaging at five time points ranging from the induction of anesthesia (T0) to discontinuation of CPB (T5). Results: In the both crystalloid [crystalloid cardioplegia group (CCG)] and blood cardioplegia [blood cardioplegia group (BCG)] groups, perfused vessel density (PVD), total vessel density (TVD), and proportion of perfused vessels (PPV) were reduced after the beginning of CPB. The observed reduction in microcirculatory parameters during CPB was only restored in patients who received blood cardioplegia and increased to baseline levels as demonstrated by the percentage changes from T0 to T5 (%Δ)T0-T5 in all the functional microcirculatory parameters [%ΔTVDT0-T5(CCG): -10.86 ± 2.323 vs. %ΔTVDT0-T5(BCG): 0.0804 ± 1.107, p < 0.001; %ΔPVDT0-T5(CCG): -12.91 ± 2.884 vs. %ΔPVDT0-T5(BCG): 1.528 ± 1.144, p < 0.001; %ΔPPVT0-T5(CCG): -2.345 ± 1.049 vs. %ΔPPVT0-T5(BCG): 1.482 ± 0.576, p < 0.01]. Conclusion: Blood cardioplegia ameliorates CPB-induced microcirculatory alterations better than crystalloid cardioplegia in patients undergoing CABG, which may reflect attenuation of the systemic inflammatory response. Future investigations are needed to identify the underlying mechanisms of the beneficial effects of blood cardioplegia on microcirculation.

WITHDRAWN: Subsegmental Thrombus in COVID-19 Pneumonia: Immuno-Thrombosis or Pulmonary Embolism? Data Analysis of Hospitalized Patients with Coronavirus Disease.

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Endophlebectomy of the common femoral vein and endovascular iliac vein recanalization for chronic iliofemoral venous occlusion.

BACKGROUND: Chronic post-thrombotic occlusion of the iliofemoral veins causes significant morbidity, which can be alleviated if venous drainage is restored. We report our technique of surgical endophlebectomy and patchplasty of the common femoral vein (CFV) in conjunction with iliac vein stenting to restore venous flow from the infrainguinal venous system to the vena cava. METHODS: There were 157 patients who underwent CFV endophlebectomy combined with iliocaval recanalization. Questionnaires were completed both preoperatively and postoperatively to allow comparison. These included the Clinical, Etiology, Anatomy, and Pathophysiology clinical classification; the Venous Clinical Severity Score; the Villalta scale; the Venous Insufficiency Epidemiological and Economic Study on Quality of Life/Symptoms; and the 36-Item Short Form Health Survey quality of life questionnaire. RESULTS: Mean follow-up duration was 14.4 ± 2.9 months (range, 10-29 months). The mean preoperative Venous Clinical Severity Score was 15.3 ± 2.2, and this fell to 6.1 ± 1.8 after treatment (P < .001). The mean preoperative Villalta score dropped from 12.7 ± 2.6 to 6.3 ± 1.4 (P < .001). The quality of life and symptom severity scores were improved after 3 months by 17.2 points for quality of life (P < .001) and 20.5 points for symptom severity (P < .001). Primary patency was 81% (124/153) and secondary patency was 89.5% (137/153) at 12 months. Wound complications related to groin incision and lymphatic fistulas were observed in 22.8% (35/153) and 28.7% (44/153), respectively. CONCLUSIONS: The hybrid operation of CFV endophlebectomy in conjunction with iliac vein recanalization should be considered a safe and effective treatment option in patients with severe post-thrombotic syndrome and iliofemoral veno-occlusive disease.

The feasibility of robotic-assisted concomitant procedures during mitral valve operations.

BACKGROUND: In this study, we present our clinical experience and midterm results with the robotic-assisted concomitant procedures during mitral valve operations. METHODS: Between March 2010 and February 2018, a total of 34 patients (8 males, 26 females; mean age 58.3 years; range, 34 to 78 years) who underwent robotic-assisted concomitant procedures during mitral valve surgery were retrospectively analyzed. Demographic characteristics of the patients, comorbidities, medical, and surgical histories, operative and laboratory results, electrocardiographic findings, postoperative intensive care unit and ward outcomes, and cardiac follow-up data were recorded. Atrial fibrillation-related medication use, stroke, or other thromboembolic events, and electrocardiographic reports in patients who underwent cryoablation were reviewed at three and 12 months after the operation. RESULTS: A total of 76 robotic-assisted concomitant procedures were performed during mitral valve repair (n=11) or replacement (n=23) in 34 patients. These procedures were cryoablation (n=29), tricuspid valve repair (n=6), tricuspid valve replacement (n=2), left atrial appendage ligation (n=32), atrial septal defect and patent foramen ovale closure (n=5), and left atrial thrombectomy (n=2). The mean preoperative EuroSCORE values were 5.1±2.5. The mean duration of cardiopulmonary bypass and cross-clamp was 156±69.4 min and 101±42 min, respectively. Normal sinus rhythm was restored in 85% of the patients (24/28) after cryoablation and two patients (5.8%) had permanent pacemaker within a year during follow-up. There was one (2.9%) mortality in the early postoperative period due to hemorrhage related to the posterior left ventricular wall rupture. No blood product was used in 82.4% of the patients. One patient had a transient cerebral event and symptoms regressed completely within two months. CONCLUSION: Technological improvements and growing experience can decrease the suspects related to prolonged operational duration during robotic-assisted cardiac surgery. Concomitant procedures in addition to mitral valve operations can be performed with low complication rates in centers with experience of robotic surgery.

Correction of dilutional anemia induces renal dysfunction in diabetic patients undergoing coronary artery bypass grafting: a consequence of microcirculatory alterations?

BACKGROUND: In this study we aimed to evaluate the effects of dilutional anemia resulting from cardiopulmonary bypass (CPB) and its correction with red blood cell (RBC) transfusion on tissue oxygenation and renal function in diabetic patients undergoing coronary artery bypass grafting (CABG). METHOD: 70 diabetic patients who underwent elective CABG and whose hematocrit values had been between 24-28% at any time during CBP were prospectively randomized and equally allocated to two groups: patients who received RBC during CPB (group I, n = 35) vs. did not receive RBC during CPB (group II, n = 35). Besides routine hemodynamic and biochemical parameters, biomarkers of ischemia and renal injury such as ischemia modified albumin (IMA), protein oxidation parameters [advanced oxidative protein products (AOPP), total thiol (T-SH)], neutrophil gelatinase-associated lipocalin (NGAL) and estimated glomerular filtration rate (eGFR) were measured in both groups. RESULTS: In group I, T-SH, NGAL and urea levels were found to be significantly increased postoperatively compared to preoperative measurements (p < 0.05). Also, postoperatively, NGAL, creatinine, aspartate aminotransferase and AOPP levels were higher in group I than group II (p < 0.05). CONCLUSION: The correction of anemia with RBC transfusion in diabetic patients undergoing CABG could increase the risk of renal injury. Further studies verifying the effects of blood transfusions at the microcirculatory level are needed to optimize the efficacy of transfusions.

Hybrid synchronous treatment of two separate cardiovascular pathologies: Coronary artery bypass grafting and endovascular aortic replacement.

Coronary artery disease and abdominal aortic aneurysm may frequently be together, particularly in elderly patients. Treatment strategies should be tailored according to the needs and specific properties of each patient. Hybrid synchronous procedures may be a choice of therapy in these patients, as well as staged procedures. Herein, we present the first hybrid synchronous case of Turkey to treat two separate cardiovascular pathologies.

Evaluating Unscheduled Readmission to Emergency Department in the Early Period.

BACKGROUND: The readmission in the early period (RAEP) is defined as the admission of a patient to emergency department (ED) for the second time within 72 hours after discharge from the ED. AIMS: The aim of this study was to determine the disease, patient, doctor, and system related causes of RAEP. STUDY DESIGN: Descriptive study. METHODS: This study is a two-stage study that was conducted at Department of Emergency, Gazi University Faculty of Medicine. The causes of RAEP were defined as disease, patient, doctor, and system related causes. RESULTS: A total of 46,800 adult patients admitted to ED during the study period and 779 (1.66%) patients required RAEP. After the exclusion criteria, 429 of these patients were included the study. The most common reasons for RAEP were renal colic in 46 (10.7%) patients. It was detected that 60.4% of the causes of RAEP were related to disease, 20.0% were related to the doctor, 12.1% were related to the patient, and 7.5% were related to the hospital management system. CONCLUSION: This study revealed that there are patient-, doctor-, and system-related preventable reasons for RAEP and the patients requiring RAEP constitute the high risk group.

Comparative effects of hemodilutional anemia and transfusion during cardiopulmonary bypass on acute kidney injury: a prospective randomized study.

AIM: Acute kidney injury after cardiopulmonary bypass has been associated with dilutional anemia during surgery. We aimed both to explore if this relation is modulated by blood transfusion and to understand the postoperative contribution of protein oxidation. METHODS: In this randomized prospective study, after ethics committee approval and informed consent, 30 patients undergoing first-time elective coronary artery bypass grafting (CABG) with hematocrit between 21% and 25% at any time during extracorporeal circulation (ECC) were randomly and equally allocated into two groups. Group I consisted of patients who received red blood cells (RBC) during ECC, while in Group II, patients did not receive any RBCs. Besides routine hemodynamic and biochemical parameters, markers of renal injury such as neutrophil gelatinase-associated lipocalin (NGAL), creatinine clearance, and protein oxidation parameters (advanced oxidative protein products [AOPP], total thiol [T-SH]) were determined in both groups. RESULTS: (1) Both cardiovascular parameters (MAP, HR) and the hospitalization period of the transfused group were not significantly different compared to the non-transfused group (P > .05); (2) While urine NGAL level (P < .05) increased and GFR (P < .01) decreased in the transfused group compared to the preoperative period, there were no significant changes in respective parameters of the non-transfused group compared to preoperative period; (3) AOPP concentrations did not change compared to postoperative periods in both groups (P > .05). However, T-SH concentration showed a transient increased at postoperative hour 6 (P < .001 vs preoperative period) but normalized at postoperative hour 24 (P > .05 versus preoperative period). CONCLUSION: These findings suggest that a hematocrit value over 21% during ECC is safe for renal functions. RBC transfusion just to increase hematocrit may be deleterious.

Oxygen fraction adjustment according to body surface area during extracorporeal circulation.

BACKGROUND: The inspiratory oxygen fraction (FiO2) is usually set between 60% and 100% during conventional extracorporeal circulation (ECC). However, this strategy causes partial oxygen pressure (PaO2) to reach hyperoxemic levels (>180 mmHg). During anesthetic management of cardiothoracic surgery it is important to keep PaO2 levels between 80-180 mmHg. The aim of this study was to assess whether adjusting FiO2 levels in accordance with body temperature and body surface area (BSA) during ECC is an effective method for maintaining normoxemic PaO2 during cardiac surgery. METHODS: After approval from the Ethics Committee of the University of Acibadem, informed consent was given from 60 patients. FiO2 adjustment strategies applied to the patients in the groups were as follows: FiO2 levels were set as 0.21 × BSA during hypothermia and 0.21 × BSA + 10 during rewarming in Group I; 0.18 × BSA during hypothermia and 0.18 × BSA + 15 during rewarming in Group II; and 0.18 × BSA during hypothermia and variable with body temperature during rewarming in Group III. Arterial blood gas values and hemodynamic parameters were recorded before ECC (T1); at the 10th minute of cross clamp (T2); when the esophageal temperature (OT) reached 34°C (T3); when OT reached 36°C (T4); and just before the cessation of ECC (T5). RESULTS: Mean PaO2 was significantly higher in Group I than in Group II at T2 and T3 (P = .0001 and P = .0001, respectively); in Group I than in Group III at T1 (P = .02); and in Group II than in Group III at T2, T3, and T4 (P = .0001 for all).  CONCLUSION: Adjustment of FiO2 according to BSA rather than keeping it at a constant level is more appropriate for keeping PaO2 between safe level limits. However, since oxygen consumption of cells vary with body temperature, it would be appropriate to set FiO2 levels in concordance with the body temperature in the rewarming period.

Robotic mitral valve replacement.

Robotic surgical techniques allow surgeons to perform mitral valve surgery. This procedure has gained acceptance, particularly for mitral valve repair in degenerative mitral disease. However, mitral repair may not always be possible, especially in severely calcified mitral valve of rheumatic origin. This study demonstrates the basic concepts and technique of robotic mitral valve replacement for valve pathologies that are not suitable for repair.

Robotic mitral valve replacement for severe rheumatic mitral disease: perioperative technique, outcomes, and early results.

OBJECTIVE: We report a case series of robotic mitral valve replacement in patients with severe rheumatic mitral disease. METHODS: From March 2010 to June 2013, a total of 63 patients underwent robotic cardiac procedures. Robotic procedures were performed using the da Vinci Si surgical systems (Intuitive Surgical, Inc, Sunnyvale, CA USA). Eighteen of the patients (28.5%) underwent robotic mitral valve replacement. Rheumatic disease was the underlying pathology in all patients. The mean (SD) follow-up period was 18 (10) months. RESULTS: The mean (SD) age and EuroSCORE of the patients were 51.2 (11) years and 4.1% (4%), respectively. Seven patients (38.8%) had an additional cardiac procedure. No operative and hospital mortality were observed. The mean (SD) cross-clamp time and cardiopulmonary bypass time were 116 (30) and 178 (54) minutes, the mean (SD) drainage was 430 (350) mL, the mean intubation time was 9.4 (7) hours, the rate of patients extubated within 6 hours or less was 94.4%, and the mean (SD) intensive care unit stay time was 30 (12) hours. Sixteen of the patients (88.8%) were discharged from the intensive care unit within the first 24 hours postoperatively. During the intensive care unit stay, one patient (5.5%) needed inotropic support. There was one early reoperation for bleeding (5.5%), one (5.5%) intensive care unit readmission, and one (5.5%) hospital readmission observed. During the midterm follow-up, there was no mortality and no need for reoperation or reintervention. CONCLUSIONS: Robotic mitral valve replacement for severe rheumatic mitral disease is technically feasible. Early results are encouraging. Patient selection criteria for robotic mitral valve surgery may be expanded to include valve replacements.

Robotic atrial septal defect closure.

Atrial septal defect (ASD) is one of the most common congenital cardiac diseases. This pathology can be treated with percutaneous devices. However, some of the ASDs are not suitable for device closure. Also, there may be device-related late complications of transcatheter ASD closure. Currently, robotic surgical techniques allow surgeons to close ASDs in a totally endoscopic fashion with a high success rate and a low complication rate. This study demonstrates the basic concepts and technique of robotic ASD closure.

Utility of cerebral oxymetry for assessing cerebral arteriolar carbon dioxide reactivity during cardiopulmonary bypass.

BACKGROUND: Our study evaluated changes in cerebral arterial oxygen saturation (rSO2) during cardiopulmonary bypass (CPB) that were caused by changes in arterial carbon dioxide tension (PaCO2). METHODS: A group of 126 patients undergoing routine, elective, first-time coronary artery bypass graft surgery (CABG) was entered into a prospective study using bilateral near-infrared spectroscopy (NIRS) before anesthetic induction (T1), after anesthetic induction (T2), and continuing at 5-minute intervals during moderate hypothermic (32°C) CPB. Pump flows were set at 2.5 L/min/m(2) and adjusted to maintain mean arterial pressure (MAP) within 10 mmHg of the MAP recorded at the initial fifth minute of CPB (T3). Thirty-two patients were excluded from data collection because MAP could not be stabilized within the target range of 60-90 mmHg. In the remaining 94 patients, after obtaining steady state flow, MAP, and oxygenation, a trial period of hypocarbia (mean PaCO2 of 30 mmHg) was induced by increasing oxygenator fresh gas flow rate (FGFR) to 2.5 L/min/m(2) (T4). A reciprocal period was then measured at reduced FGFR (0.75 L/min/m(2)) (T5). RESULTS: After 20 minutes of a higher (2.75 L/min/m(2)) (FGFR), mean PaCO2 decreased from a baseline of 38 ± 4 mmHg to 30 ± 2 mmHg. This was associated with a parallel decrease (-10 ± 9%) in mixed cerebral oxygen saturation without alteration of mean arterial oxygen tension (PaO2), lactate, MAP, CPB flow, or other parameters implying increased cerebral oxygen extraction. CONCLUSION: Parallel changes in PaCO2 and rSO2 occur during CPB when other variables remain constant, and are due to the effects of carbon dioxide on cerebral arterioles. Cerebral oxygen saturation measured by NIRS may be a useful indirect measure of PaCO2 when continuous blood gas analysis is not possible during open-heart surgery. Cerebral oximetry values may be useful measurements for setting an optimum gas flow rate through the oxygenator.

Right ventricular endomyocardial fibrosis mimicking Ebstein anomaly in a patient with Behçet's disease: case report and review of the literature.

Behçet's disease is a multisystemic, chronic inflammatory disorder with diffuse clinical manifestations including the cardiovascular system. Endomyocardial fibrosis is a rarely seen complication of Behçet's disease leading to progressive heart failure. We report a case of right ventricular endomyocardial fibrosis mimicking Ebstein anomaly in a 26-year-old male Turkish patient with Behçet's disease, who had heart failure symptoms. In addition, the previously reported cases of endomyocardial fibrosis complicating Behçet's disease are reviewed in this article.

Use of bone wax is related to increased postoperative sternal dehiscence.

AIM: To investigate the relation between use of bone wax and postoperative sternal dehiscence after cardiac surgery. MATERIAL AND METHODS: Five thousnad three hundred and eighteen consecutive patients who underwent cardiac surgery between 1999 and 2009 were evaluated prospectively. Perioperative use of bone wax, perioperative data and outcome parameters were recorded. Multivariate logistic regression analysis was performed to define independent risk factors for postoperative sternal dehiscence. RESULTS: Bone wax was used in a total of 1151 (21%) patients. Postoperative sternal dehiscence was detected in 88 (1.6%) patients. The postoperative sternal dehiscence rate was 1.4% in patients without bone wax and 2.5% in patients with bone wax (p = 0.001). The rate of bone wax use was 36.4% in patients with sternal dehiscence and 21.4% in patients without sternal dehiscence (p < 0.001). Independent risk factors for postoperative sternal dehiscence were defined as: age > 70 (OR = 1.9, 95% CI: 1.2-3.1, p = 0.005), chronic obstructive lung disease (OR = 2.4, 95% CI: 1.5-3.9, p < 0.001), use of bone wax (OR = 1.6, 95% CI: 1.03-2.5, p = 0.03), nonelective operation (OR = 2, 95% CI: 1.1-3.4, p = 0.009), and body mass index > 30 (OR = 2.2, 95% CI: 1.4-3.5, p < 0.001). CONCLUSIONS: Our findings suggest that use of bone wax may be associated with increased postoperative sternal dehiscence after cardiac surgery. Thus liberal use of bone wax should be restricted.

A hybrid therapy as a third approach for type 1 proximal endoleak of thoracic endovascular aortic replacement: Caroticocarotid bypass and re-redo endovascular therapy.

INTRODUCTION: In selected cases with thoracic aortic aneurysm (TAA), thoracic endovascular aortic replacement (TEVAR) is commonly used and shall be proper therapy method. We are presenting a case of TAA previously treated twice by endovascular aortic approaches and complicated by type 1 endoleak. CASE: A 67-year-old male patient was admitted to our clinic with back pain at rest. He underwent TEVAR five years ago, twice in 6 month. With contrasted computed tomography of chest and abdomen, a new type 1 proximal endoleak was diagnosed, and after routine preoperative follow up, the patient was operated on. At the same session right to left caroticocarotid bypass and re-redo TEVAR were performed. The new endovascular graft was placed as the proximal landing zone to be set between left carotid artery and brachiocephalic truncus. The patient was discharged on postoperative day 4 without any problems. CONCLUSION: As new techniques and methods have been developed, mortality rates have decreased to 2-3% but in older and high risk patients, mortality rates still remain high [1]. TEVAR is a safe and effective treatment method in the proper and selected patients with thoracic artery aneurysm [2]. Moreover, TEVAR can also be performed as a part of hybrid procedures for arcus aortic aneurysms [3]. But it should be kept in mind that late secondary intervention rates are higher in TEVAR.

Simultaneous endovascular stent and renal stent placement for acute type B aortic dissection with malperfusion of kidney.

Acute aortic dissection frequently causes life-threatening organ ischemia. The optimal therapy for acute type-B aortic dissection is still controversial. Surgery for acute dissection with organ malperfusion is known to carry a high morbidity and mortality; however endovascular treatment is becoming an alternative form of treatment. We report a clinical case of emergency percutaneous thoracal aorta endovascular stenting and renal artery stenting in a patient who had renal malperfusion and acute renal failure due to acute type-B dissection. The present case is a fundamental examples of collaboration between the cardiologist and cardiovascular surgeon in a hybrid procedure.

A right coronary artery saccular aneurysm leading to an embolic myocardial infarction during diagnostic cardiac catheterization: A case report.

Coronary artery aneurysms are localized dilatations greater than 1.5 times the diameter of the adjacent segments. These rarely seen abnormalities may lead to serious life-threatening complications such as myocardial infarction, coronary perforation and death. Here, we present a case of periprocedural thromboembolic inferior myocardial infarction arising from a proximal right coronary artery saccular aneurysm during a diagnostic coronary angiography in a stable 70-year-old patient.