Lactate and Lactate Clearance Are Predictive Factors for Mortality in Patients with Extracorporeal Membrane Oxygenation.

INTRODUCTION: Findings of inadequate tissue perfusion might be used to predict the risk of mortality. In this study, we evaluated the effects of lactate and lactate clearance on mortality of patients who had undergone extracorporeal membrane oxygenation (ECMO). METHODS: Patients younger than 18 years old and who needed venoarterial ECMO support after surgery for congenital heart defects, from July 2010 to January 2019, were retrospectively analyzed. Patients successfully weaned from ECMO constituted Group 1, and patients who could not be weaned from ECMO were in Group 2. Postoperative clinics and follow-ups of the groups including mortality and discharge rates were evaluated. RESULTS: There were 1,844 congenital heart surgeries during the study period, and 55 patients that required ECMO support were included in the study. There was no statistically significant difference between the groups regarding demographics and operative variables. The sixth-, 12th-, and 24th-hour lactate levels in Group 1 were statistically significantly lower than those in Group 2 (P=0.046, P=0.024, and P<0.001, respectively). There were statistically significant differences regarding lactate clearance between the groups at the 24th hour (P=0.009). The cutoff point for lactate level was found as ≥ 2.9, with 74.07% sensitivity and 78.57% specificity (P<0.001). The cutoff point for lactate clearance was determined as 69.44%, with 59.26% sensitivity and 78.57% specificity (P=0.003). CONCLUSION: Prognostic predictive factors are important to initiate advanced treatment modalities in patients with ECMO support. In this condition, lactate and lactate clearance might be used as a predictive marker.

Lactate and Lactate Clearance Are Predictive Factors for Mortality in Patients with Extracorporeal Membrane Oxygenation

ABSTRACT Introduction: Findings of inadequate tissue perfusion might be used to predict the risk of mortality. In this study, we evaluated the effects of lactate and lactate clearance on mortality of patients who had undergone extracorporeal membrane oxygenation (ECMO). Methods: Patients younger than 18 years old and who needed venoarterial ECMO support after surgery for congenital heart defects, from July 2010 to January 2019, were retrospectively analyzed. Patients successfully weaned from ECMO constituted Group 1, and patients who could not be weaned from ECMO were in Group 2. Postoperative clinics and follow-ups of the groups including mortality and discharge rates were evaluated. Results: There were 1,844 congenital heart surgeries during the study period, and 55 patients that required ECMO support were included in the study. There was no statistically significant difference between the groups regarding demographics and operative variables. The sixth-, 12th-, and 24th-hour lactate levels in Group 1 were statistically significantly lower than those in Group 2 (P=0.046, P=0.024, and P<0.001, respectively). There were statistically significant differences regarding lactate clearance between the groups at the 24th hour (P=0.009). The cutoff point for lactate level was found as ≥ 2.9, with 74.07% sensitivity and 78.57% specificity (P<0.001). The cutoff point for lactate clearance was determined as 69.44%, with 59.26% sensitivity and 78.57% specificity (P=0.003). Conclusion: Prognostic predictive factors are important to initiate advanced treatment modalities in patients with ECMO support. In this condition, lactate and lactate clearance might be used as a predictive marker.

Factors affecting the clinical outcomes in pediatric post-cardiotomy patients requiring perioperative peritoneal dialysis.

OBJECTIVE: Fluid overload is associated with increased mortality and morbidity in pediatric cardiac surgery. In the pediatric age group, peritoneal dialysis might improve postoperative outcome with avoiding fluid overload and electrolyte imbalance. It preserves hemodynamic status with the advantage of passive drainage. In this study, we are reporting our results of peritoneal dialysis after cardiac surgery. METHODS: In this retrospective study, we evaluated the patients who underwent pediatric cardiac surgery in our hospital between December 2010 and January 2020. Patients who required peritoneal dialysis during hospitalization period were included in the study. Patients' clinical status and outcomes were evaluated. RESULTS: Peritoneal dialysis was performed to 89 patients during the study period. The age varies from the newborn to 4 years old. The indication of peritoneal dialysis was prophylactic in 68.5% (n=61) and for the treatment in 31.5% (n=28). There were 31 mortalities. The risk factors for the mortality were preoperative lower age, longer cardiopulmonary bypass time, lengthened intubation, lengthened inotropic support, and requirement of extracorporeal membrane oxygenation (p<0.0001). CONCLUSION: Earlier initiation of peritoneal dialysis in pediatric cardiac surgery helps maintain hemodynamic instability by avoiding fluid overload, considering the difficulty in the treatment of electrolyte imbalance and diuresis.

Factors affecting the clinical outcomes in pediatric post-cardiotomy patients requiring perioperative peritoneal dialysis

SUMMARY OBJECTIVE: Fluid overload is associated with increased mortality and morbidity in pediatric cardiac surgery. In the pediatric age group, peritoneal dialysis might improve postoperative outcome with avoiding fluid overload and electrolyte imbalance. It preserves hemodynamic status with the advantage of passive drainage. In this study, we are reporting our results of peritoneal dialysis after cardiac surgery. METHODS: In this retrospective study, we evaluated the patients who underwent pediatric cardiac surgery in our hospital between December 2010 and January 2020. Patients who required peritoneal dialysis during hospitalization period were included in the study. Patients' clinical status and outcomes were evaluated. RESULTS: Peritoneal dialysis was performed to 89 patients during the study period. The age varies from the newborn to 4 years old. The indication of peritoneal dialysis was prophylactic in 68.5% (n=61) and for the treatment in 31.5% (n=28). There were 31 mortalities. The risk factors for the mortality were preoperative lower age, longer cardiopulmonary bypass time, lengthened intubation, lengthened inotropic support, and requirement of extracorporeal membrane oxygenation (p<0.0001). CONCLUSION: Earlier initiation of peritoneal dialysis in pediatric cardiac surgery helps maintain hemodynamic instability by avoiding fluid overload, considering the difficulty in the treatment of electrolyte imbalance and diuresis.

Cardiac Echinococcosis: A Single-Centre Study with 25 Patients.

BACKGROUND: In this study, we aimed to analyse patients who underwent surgery for cardiac echinococcosis in our department. METHODS: Between June 2005 and June 2013, 25 patients (15 male, 10 female) underwent cardiac hydatid cyst operation. The mean patient age was 33.4±12.6 (15-75) years. RESULTS: The most common presenting symptom was dyspnoea. Cysts were located only in the heart in 16 patients, lung in 4 patients, liver in 4 patients, and brain with lung involvement in 1 patient. Concomitant cardiac and pulmonary surgery was performed in 2 patients. The cardiac hydatid cysts were intracavitary in 11 patients and extracavitary in 14 patients. We used cardiopulmonary bypass in all but 1 patient, who presented with an extracavitary cyst. In 3 patients, surgery was performed with cardiopulmonary bypass without cross-clamping of the aorta. There were no mortalities in the early follow-up period. CONCLUSION: Cardiac echinococcosis is a rare but fatal disease and should be surgically treated when diagnosed. There is some controversy about how echinococcosis spreads to the heart (via haematogenous spread or direct extension from adjacent structures). According to our study, we think that haematogenous spread is the main method of the distribution of cardiac echinococcosis, and the direct extension method from adjacent structures must be questioned.

Short-term and mid-term results with the Sorin Freedom Solo aortic valve.

BACKGROUND AND AIM OF THE STUDY: The study aim was to present the short- and mid-term results for patients who underwent aortic valve replacement (AVR) with the Sorin Freedom Solo third-generation stentless prosthetic valve. METHODS: AVR with a Sorin Freedom Solo valve was performed in 14 patients between March 2006 and March 2011. Patients aged > or = 60 years (male:female ratio 6:8; mean age 73.28 +/- 5.42 years) who required AVR with the Sorin Freedom Solo valve according to the surgeon's choice were included in the study. The valvular prosthesis was implanted in the supra-annular position, using a single suture line. RESULTS: Eight patients underwent an isolated AVR; combined interventions were carried out in the other patients due to concomitant cardiac disease. One patient died during the immediate perioperative period, and two more during the follow up, from non-cardiac causes. The mean maximum transvalvular gradient of patients with aortic stenosis was 88.1 +/- 20.2 mmHg, and this fell to 26.4 +/- 7.6 mmHg during the early postoperative period. The mean gradient at one year of follow up was further decreased to 19.4 +/- 5.3 mmHg. The left ventricular end-diastolic and end-systolic diameters were also significantly reduced, from 4.8 +/- 0.9 to 4.3 +/- 0.6 cm and from 3.2 +/- 0.6 to 2.8 +/- 5.3 cm, respectively. The average left ventricular ejection fraction was 60.2 +/- 4.9% preoperatively, and 63.2 +/- 2.1% at one year after surgery (p = NS). No paravalvular leakage, endocarditis, prosthesis failure or neurologic events were reported among patients. CONCLUSION: The Sorin Freedom Solo stentless valve has provided good early and intermediate-term results. Implantation of the prosthesis is straightforward, with low rates of morbidity and mortality. However, these data require further support from larger patient series and long-term follow up.

Lateral cavoatriotomy for partial anomalous pulmonary venous connection to the superior vena cava.

PURPOSE: Surgical correction of the partial anomalous pulmonary venous connection (PAPVC) draining into the superior vena cava (SVC) has been associated with sinus node dysfunction and venous return obstruction, postoperatively. We present the results of our lateral cavoatriotomy approach with little modifications to avoid injury to the sinus node and its artery. METHODS: 32 patients who underwent surgical repair of PAPVC to SVC with modified lateral cavoatriotomy in our clinic between January 2003 and January 2009 were evaluated retrospectively. RESULTS: Median age was 6 years (2-32 years). The mean follow-up time was 65.8 ± 23.7 months (36-111 months). There were no early or late deaths. No patients required reoperation. New onset of arrhythmia had developed in two patients and resolved before hospital discharge. Stenosis of the SVC in one patient had developed 11 months after the operation and was treated with balloon angioplasty, successfully. No sinus node dysfunction or venous return obstruction was detected in their last follow-up. CONCLUSION: Cavoatrial incision for repair of PAPVC to SVC may become a safer surgical technique with some modifications.

"V-PLASTY": a novel technique to reconstruct pulmonary valvular and annular stenosis in patients with right ventricular outflow tract obstruction.

BACKGROUND: The goal of repair of right ventricular outflow tract obstruction with or without Tetralogy of Fallot (TOF) is to eliminate valvular and/or subvalvular obstruction. However, this operation has a high risk of late complication of pulmonary insufficiency. In this study, we aimed to present early period results of our new technique that we call "V-Plasty" developed to prevent pulmonary insufficiency after pulmonary valve reconstruction in selected patients. METHODS: Between January 2006 and January 2010, we performed V-plasty for pulmonary valve reconstruction in 10 patients. Eight patients (5 males, 3 females) had TOF and 2 patients (1 male, 1 female) had atrial septal defect concomitant with pulmonary valve stenosis. Patient selection for V-plasty reconstruction was made due to the pulmonary valve anatomy and degree of stenosis. The mean follow-up time was 55.7 ± 16.2 months (ranging from 32 to 80 months). RESULTS: Functional capacity of the patients improved immediately after the surgery. There were no mortality and re-operation in follow-up period. Patients were followed up with echocardiography one week after the operation, at 1st, 6th, 12th months and annually. There was no pulmonary insufficiency. CONCLUSIONS: Operative correction of the pulmonary outflow tract obstruction with or without TOF, frequently requires transannular enlargement because of the infundibular and/or annular-valvular obstruction. This conventional technique is usually a reason for late pulmonary insufficiency. In our study, we have not seen pulmonary insufficiency in early term follow-up period. Our early term results are encouraging, but long term follow-up results are needed with large case series.

Urgent surgical management for embolized occluder devices in childhood: single center experience.

BACKGROUND: In this study, we sought to analyze our experience in urgent surgical management for embolized cardiac septal and ductal occluder devices resulting from trans-catheter closure of atrial septal defect, ventricular septal defect and patent ductus arteriosus in childhood patient group. METHODS: We retrospectively reviewed 9 patients (aged 2-15 years) who underwent urgent surgery due to cardiac septal and ductal occluder embolization between January 2007 and December 2010. Congenital defects were atrial septal defect (n = 6), ventricular septal defect (n = 1), and patent ductus arteriosus (n = 2). Risk factors for device embolization and urgent surgical management techniques for embolized device removal were discussed. RESULTS: Removal of embolized devices in all cases and repair of damaged tricuspid valve in 2 patients were performed. Inevitably, all congenital defects were closed or ligated up to the primary defect. Total circulator arrest necessitated in 1 patient with ascending aortic device embolization. All operations were completed successfully and no hospital mortality or morbidity was encountered. CONCLUSIONS: Although closure of left to right shunting defects by percutaneous occluder devices has a lot of advantages, device embolization is still a major complication. If embolized device retrieval fails with percutaneous intervention attempts, surgical management is the only method to remove embolized devices. In this circumstance, to provide an uneventful perioperative course, urgent management strategies should be well planned.

Treatment outcomes of postoperative mediastinitis in cardiac surgery; negative pressure wound therapy versus conventional treatment.

BACKGROUND: The aim of the present study is to compare negative pressure wound therapy versus conventional treatment outcomes at postoperative mediastinitis after cardiac surgery. METHODS: Between January 2000 and December 2011, after 9972 sternotomies, postoperative mediastinitis was diagnosed in 90 patients. The treatment modalities divided the patients into two groups: group 1 patients (n = 47) were initially treated with the negative pressure wound therapy and group 2 patients (n = 43) were underwent conventional treatment protocols. The outcomes were investigated with Kaplan-Meier method, log-rank test, Student's test and Fisher's exact test. RESULTS: The 90-days mortality was found significantly lower in the negative pressure wound group than in the conventionally treated group. Overall survival was significantly better in the negative pressure wound group than in the conventionally treated group. CONCLUSION: Negative pressure wound therapy is safe and reliable option in mediastinitis after cardiac surgery, with excellent survival and low failure rate when compared with conventional treatments.

Pericardial monocusp reconstruction for pulmonary valve vegetation secondary to patent ductus arteriosus.

A case of pulmonary valve endocarditis in a patient with a ductus arteriosus (PDA) is reported. The PDA was ligated, the septal leaflet of the pulmonary valve was excised, and a pericardial monocusp reconstruction was performed.

Leiomyosarcoma protruding into the left ventricle during diastole: report of a case.

Cardiac leiomyosarcoma is a rare tumor with poor survival prospects. Surgery prolongs survival, but the tumor often recurs early after surgery. The diagnosis is often made by transthoracic echocardiography. Magnetic resonance imaging and computed tomography are required to characterize the location and extent of cardiac masses. In this report, we present a patient with a leiomyosarcoma that was resected completely. The tumor was located in the left atrium, mimicked a myxoma, and protruded into the left ventricle during diastole.

P-wave dispersion between transcatheter and surgical closure of secundum-type atrial septal defect in childhood.

Patients with atrial septal defect have an increased risk for atrial fibrillation. Increased P-wave dispersion predicts the development of atrial fibrillation. The aim of this study was to determine difference in P dispersion between transcatheter closure with Amplatzer septal occluder and surgical closure in childhood. A total of 68 children (the mean age was 7.2 plus or minus 3.3 years; the mean secundum atrial septal defects diameter was 17.3 plus or minus 5.4 millimetres) were evaluated in this study. Transcatheter closure was attempted in 41 children with secundum atrial septal defects, and the defect in 27 patients was closed by surgical techniques. P maximum, P minimum and P dispersion were measured by the 12-lead surface electrocardiography. P maximum, P minimum and P dispersion were found to be similar in patients with pre- and post-procedure (98.0 plus or minus 19.3 versus 95.1 plus or minus 23.0 milliseconds; 68.0 plus or minus 20.8 versus 67.6 plus or minus 24.3 milliseconds, 29.9 plus or minus 11.0 versus 27.1 plus or minus 12.1 milliseconds, respectively). There was no statistical significance in the comparison of P dispersion between the two groups. But in the surgical group, P-wave dispersion was decreased more significantly compared with baseline values (p-value equal to 0.03). In conclusion, there is no P dispersion between transcatheter closure with Amplatzer septal occluder and surgical closure of secundum atrial septal defect.

Randomized comparison of vasodilator effects of iloprost versus diltiazem on flow and pathologic changes in radial arteries: mid-term angiographic control study of the comparison of vasodilators on radial artery vasospasm.

BACKGROUND: The increasing prevalence of routine radial artery (RA) use in coronary artery bypass grafting (CABG) has rendered the pharmacologic prevention of spasm of this artery a critical consideration in the early postoperative period and in the long-term outcome. In this study, we compared the effects of iloprost and diltiazem on vasospasm. METHODS: Seventy patients who underwent CABG with the RA were randomized into 2 groups, and the vasodilator effects of iloprost and diltiazem were studied prospectively. RA flow was measured with Doppler ultrasonography. Following harvesting, a 5-mm piece was removed from the RA distally for pathologic examination. In group B, diltiazem was infused before removing the RA, whereas in group A, iloprost infusion was initiated 5 days before surgery. At the end of a 2-year follow-up, each patient underwent coronary angiography. RESULTS: Doppler flow measurements made during harvesting revealed a statistically significant reduction in flow, and a pathologic examination of the RAs revealed significant luminal narrowing in group B. A 2-year angiographic follow-up revealed all of the RA grafts in group A to be patent. CONCLUSIONS: Our evaluation of the results revealed the superior efficacy of iloprost over diltiazem in preventing RA spasm in the early period, and the 2-year angiographic findings showed that the use of iloprost produced superior mid-term patency.

Pulmonary valve implantation with the new Shelhigh Injectable Stented Pulmonic Valve.

BACKGROUND: Pulmonary regurgitation (PR) occurs frequently after tetralogy of Fallot (TOF) repair, impairing long-term prognosis and necessitating reinterventions. Myocardial damage, invasiveness, and the risks of pulmonary valve replacement (PVR) therefore need to be minimized. The new Shelhigh Injectable Stented Pulmonic Valve (Shelhigh Inc, Union, NJ) allows implantation without cardiopulmonary bypass (CPB) under direct control. METHODS: Twelve symptomatic patients (age, 21.3 +/- 12.5; range, 5.8 to 53.5 years) with severe PR and progressive right ventricular (RV) dilatation with dysfunction received the Shelhigh valve in sizes 21 (n = 1), 25 (n = 4), 27 (n = 3), 29 (n = 2), and 31 mm (n = 2). RESULTS: Valve insertion was successful and hemodynamic performance excellent in all: peak systolic gradient, 14.5 +/- 4.6 (range, 10 to 20) mm Hg; mean gradient, 6.3 +/- 1.6 (range, 4 to 8) mm Hg. Four patients underwent concomitant procedures on CPB: one reduction plasty of a dilated main pulmonary artery, two tricuspid valve repairs, and one VSD closure. Early recovery was uneventful. There were no reoperations. During a mean follow-up of 5.4 +/- 4.3 months (range, 0.3 to 10.6 months) echocardiography showed good results, with low gradients and recovered RV function in all. All presented in New York Heart Association functional class 1 at the latest follow-up. CONCLUSIONS: The Shelhigh valve allows easy PVR without CPB up to large valve sizes, with less invasiveness compared with a conventional approach. Further follow-up is needed to assess its durability and long-term performance.

Off-pump pulmonary valve implantation.

In congenital heart surgery, especially after Tetralogy of Fallot (TOF), problems from the right ventricular outflow tract may lead to serious complications as morbidity and mortality. To resolve these problems by reoperating using cardiopulmonary bypass (CPB) with valves or conduits is affecting surgical morbidity and mortality rates. The ability of a newly developed Shelhigh Pulmonic Valved Injectable No-React-Treated Conduit (NR 4000-PA MIS Shelhigh Inc., Union, NJ, USA) to be implanted into a beating heart provides great advantages for both patient and surgeon. Early results of the first application in our clinic are presented in this article.

Retrospective analysis of surgically treated infective endocarditis cases.

BACKGROUND: Prosthetic valve endocarditis (PVE) and native valve endocarditis (NVE) both cause high rates of morbidity and mortality and are significant health problems in our community. Optimal timing of the surgical intervention depends on the hemodynamic stability of the patient. In the present study, we retrospectively evaluated the clinical status, bacteriology, morbidity, and mortality parameters of infective endocarditis cases that were treated surgically. METHODS: Thirty patients (20 male and 10 female) who underwent cardiac valve surgery between April 2001 and December 2006 were included in the study. The mean (SD) age of the patients was 36.5 +/- 5.42 years. Thirty-five surgical operations were conducted on 30 patients. We evaluated the patient demographic, etiologic, and surgical data retrospectively with respect to mortality and morbidity. RESULTS: The mean time to develop PVE was 13 months. We recorded a mortality rate of 16.6% (2 deaths in NVE operations and 3 deaths in PVE operations). Repeat surgeries were performed in 2 aortic valve cases and 3 mitral valve cases in which paravalvular leakage was noticed in the prosthetic valves. CONCLUSION: Despite significant medical and surgical advances, both NVE and PVE still continue to be causes of high mortality and morbidity rates in cardiac surgery.

Deep pericardial suture vs apical suction for off-pump bypass grafting.

Hemodynamic changes during heart luxation and stabilization are major problems in off-pump coronary artery bypass surgery. The hemodynamic effects of an apical suction device were compared with those of the classic posterior pericardial suture in 45 patients with multivessel coronary disease undergoing off-pump coronary artery bypass. Mean age was 63.78 +/- 8.11 years; 31 patients were male and 14 were female. Transesophageal Doppler echocardiography was used for hemodynamic monitoring. All hemodynamic parameters were significantly better when the apical suction device was used to position the heart for anastomoses on the posterior descending and circumflex arteries.

Predictive risk factors for early mortality in operative treatment for chronic ischemic mitral insufficiency.

BACKGROUND: The combination of coronary artery bypass grafting and mitral valve surgeries is closely associated with high in-hospital mortality and morbidity. In this study, we sought to analyze the factors that influence early mortality in 68 patients undergoing coronary artery bypass grafting + mitral valve surgery due to ischemic mitral insufficiency. METHODS: Of 1183 patients undergoing coronary bypass surgery between April 2002 and June 2006, 68 patients (42 male and 26 female) 42 to 78 years of age (mean +/- SD, 59.3 +/- 9.1) underwent mitral valve surgery accompanying coronary bypass surgery (survival, n = 59; mortality, n = 9). The cases were analyzed regarding the demographic, preoperative, and perioperative risk factors that influence mortality. RESULTS: The early mortality rate was found to be 13.2% (9/68) in patients with ischemic mitral regurgitation undergoing simultaneous coronary bypass and mitral valve surgeries. New York Heart Association class > or =3, left ventricle end-systolic volume, left ventricle end-systolic diameter, cardiopulmonary perfusion time, preoperative unstable angina pectoris, intra-aortic balloon application, and age >65 years were determined to be statistically significant risk factors that influence early in-hospital mortality.Conclusion. Surgery, despite having a high mortality risk in patients with ischemic mitral insufficiency, is considered to be a treatment measure that generally improves the quality of life and prolongs life.