Turkish Society of Cardiovascular Surgery (TSCVS) Proposal for use of ECMO in respiratory and circulatory failure in COVID-19 pandemic era.

The document is prepared to guide the members of the The Turkish Society of Cardiovascular Surgery (TSCVS) and other extracorporeal membrane oxygenation (ECMO) centers worldwide to share experiences in using ECMO in COVID-19 pandemic.

The effect of exposure to 1800 MHz radiofrequency radiation on epidermal growth factor, caspase-3, Hsp27 and p38MAPK gene expressions in the rat eye.

OBJECTIVE: Radiofrequency electromagnetic fields (RF-EMF) may induce DNA damage and oxidative stress in human lens epithelial cells (LECs). We aimed to investigate the expression levels of heat shock protein 27 (Hsp27), p38 mitogen-activated protein kinase (p38MAPK), epidermal growth factor receptor (EGFR) and caspase-3 gene expression levels in rat eye that was exposed to 1800 MHz RF-EMF. METHODS: Thirty-seven female Wistar albino rats were divided into three groups. The rats in the study group (n = 9) were exposed to 1800 MHz RF-EMF at an electric field 6.8 ± 0.1 V/m and 0.06 W/kg specific absorption rate (SAR) for 2 hours per day for eight weeks. Sham group (n = 9) was kept under similar conditions as the exposed group without exposure to RF-EMF. The rats in all three groups were sacrificed and their eyes were removed. Hsp27, p38MAPK, EGFR, caspase-3 gene expression levels were investigated in detail with real-time polymerase chain reactions (Real-Time PCR). RESULTS: caspase-3 and p38MAPK gene expression were significantly upregulated in the ocular tissues following exposure to RF-EMF (p < 0.05). CONCLUSION: According to our findings, eye cells recognize EMF as a stress factor, and in response, activate caspase-3 and p38MAPK gene expressions. These results confirm that RF-EMF can cause cellular damage in rat ocular cells (Tab. 2, Fig. 3, Ref. 37).

Primary Left Cardiac Angiosarcoma with Mitral Valve Involvement Accompanying Coronary Artery Disease.

We report here on a 43-year-old female patient presenting with non-ST elevation myocardial infarction, severe mitral regurgitation, and mild mitral stenosis secondary to encroachment of the related structures by a primary cardiac angiosarcoma. A coronary angiography revealed significant stenosis in the left main and left circumflex arteries and at exploration, the tumour was arising from posterior left atrial free wall, invading the posterior mitral leaflet, and extending into all of the pulmonary veins and pericardium. Therefore, no further intervention was performed, except for left internal mammarian artery to left anterior descending artery anastomosis and biopsy. As far as we know, this case is unique with respect to its presentation.

The effect of radiofrequency radiation generated by a Global System for Mobile Communications source on cochlear development in a rat model.

OBJECTIVE: This study aimed to determine the effect of radiofrequency radiation generated by 900 and 1800 MHz Global System for Mobile Communications sources on cochlear development in the rat model. METHODS: Eight pregnant albino Wistar rats were divided into three groups: control, 900 MHz and 1800 MHz. The latter two groups of pregnant rats were exposed to radiofrequency radiation for 1 hour per day starting on the 12th day of pregnancy until delivery. The rats in the control, 900 MHz and 1800 MHz groups gave birth to 24, 31 and 26 newborn rats respectively. Newborn rats in the 900 MHz and 1800 MHz groups were exposed to radiofrequency radiation for 1 hour per day for 21 days after delivery. Hearing evaluations of newborn rats were carried out using distortion product otoacoustic emissions testing. Eight newborn rats were randomly selected from each group for electron microscopic evaluation. RESULTS: Distortion product otoacoustic emission tests revealed no significant difference among the groups, but electron microscopic evaluation revealed significant differences among the groups with regard to the number of normal, apoptotic and necrotic cells. CONCLUSION: The findings indicated cellular structural damage in the cochlea caused by radiofrequency radiation exposure during cochlear development in the rat model.

Correlation between the functional impairment of bone marrow-derived circulating progenitor cells and the extend of coronary artery disease.

BACKGROUND: Bone marrow-derived circulating progenitor cells (BM-CPCs) in patients with coronary heart disease are impaired with respect to number and functional activity. However, the relation between the functional activity of BM-CPCs and the number of diseased coronary arteries is yet not known. We analyzed the influence of the number of diseased coronary arteries on the functional activity of BM-CPCs in peripheral blood (PB) in patients with ischemic heart disease (IHD). METHODS: The functional activity of BM-CPCs was measured by migration assay and colony forming unit in 120 patients with coronary 1 vessel (IHD1, n = 40), coronary 2 vessel (IHD2, n = 40), coronary 3 vessel disease (IHD3, n = 40) and in a control group of healthy subjects (n = 40). There was no significant difference of the total number of cardiovascular risk factors between IHD groups, beside diabetes mellitus (DM), which was significantly higher in IHD3 group compared to IHD2 and IHD1. RESULTS: The colony-forming capacity (CFU-E: p < 0.001, CFU-GM: p < 0.001) and migratory response to stromal cell-derived factor 1 (SDF-1: p < 0.001) as well as vascular endothelial growth factor (VEGF: p < 0001) of BM-CPCs were reduced in the group of patients with IHD compared to control group. The functional activity of BM-CPCs was significantly impaired in patients with IHD3 as compared to IHD1 (VEGF: p < 0.01, SDF-1: p < 0.001; CFU-E: p < 0.001, CFU-GM: p < 0.001) and to IHD2 (VEGF: p = 0.003, SDF-1: p = 0.003; CFU-E: p = 0.001, CFU-GM: p = 0.001). No significant differences were observed in functional activity of BM-CPCs between patients with IHD2 and IHD1 (VEGF: p = 0.8, SDF-1: p = 0.9; CFU-E: p = 0.1, CFU-GM: p = 0.1). Interestingly, the levels of haemoglobin AIc (HbAIc) correlated inversely with the functional activity of BM-CPCs (VEGF: p < 0.001, r = -0.8 SDF-1: p < 0.001, r = -0.8; CFU-E: p = 0.001, r = -0.7, CFU-GM: p = 0.001, r = -0.6) in IHD patients with DM. CONCLUSIONS: The functional activity of BM-CPCs in PB is impaired in patients with IHD. This impairment increases with the number of diseased coronary arteries. Moreover, the regenerative capacity of BM-CPCs in ischemic tissue further declines in IHD patients with DM. Furthermore, monitoring the level of BM-CPCs in PB may provide new insights in patients with IHD.

Rationale and design of the coronary artery bypass grafting surgery off or on pump revascularization study: a large international randomized trial in cardiac surgery.

BACKGROUND: Uncertainty remains regarding the benefits and risks of the technique of operating on a beating heart (off pump) for coronary artery bypass grafting (CABG) surgery versus on-pump CABG. Prior trials had few events and relatively short follow-up. There is a need for a large randomized, controlled trial with long-term follow-up to inform both the short- and long-term impact of the 2 approaches to CABG. METHODS: We plan to randomize 4,700 patients in whom CABG is planned to undergo the procedure on pump or off pump. The coprimary outcomes are a composite of total mortality, myocardial infarction (MI), stroke, and renal failure at 30 days and a composite of total mortality, MI, stroke, renal failure, and repeat revascularization at 5 years. We will also undertake a cost-effectiveness analysis at 30 days and 5 years after CABG surgery. Other outcomes include neurocognitive dysfunction, recurrence of angina, cardiovascular mortality, blood transfusions, and quality of life. RESULTS: As of May 3, 2011, CORONARY has recruited >3,884 patients from 79 centers in 19 countries. Currently, patient's mean age is 67.6 years, 80.7% are men, 47.0% have a history of diabetes, 51.4% have a history of smoking, and 34.4% had a previous MI. In addition, 20.9% of patients have a left main disease, and 96.6% have double or triple vessel disease. CONCLUSIONS: CORONARY is the largest trial yet conducted comparing off-pump CABG to on-pump CABG. Its results will lead to a better understanding of the safety and efficacy of off-pump CABG.

Rationale and design of the coronary artery bypass grafting surgery off or on pump revascularization study: a large international randomized trial in cardiac surgery

Background Uncertainty remains regarding the benefits and risks of the technique of operating on a beating heart(off pump) for coronary artery bypass grafting (CABG) surgery versus on-pump CABG. Prior trials had few events and relativelyshort follow-up. There is a need for a large randomized, controlled trial with long-term follow-up to inform both the short- andlong-term impact of the 2 approaches to CABG.Methods We plan to randomize 4,700 patients in whom CABG is planned to undergo the procedure on pump or offpump. The coprimary outcomes are a composite of total mortality, myocardial infarction (MI), stroke, and renal failure at30 days and a composite of total mortality, MI, stroke, renal failure, and repeat revascularization at 5 years. We will alsoundertake a cost-effectiveness analysis at 30 days and 5 years after CABG surgery. Other outcomes include neurocognitivedysfunction, recurrence of angina, cardiovascular mortality, blood transfusions, and quality of life.Results As of May 3, 2011, CORONARY has recruited N3,884 patients from 79 centers in 19 countries. Currently,patient's mean age is 67.6 years, 80.7% are men, 47.0% have a history of diabetes, 51.4% have a history of smoking, and34.4% had a previous MI. In addition, 20.9% of patients have a left main disease, and 96.6% have double or triplevessel disease.Conclusions CORONARY is the largest trial yet conducted comparing off-pump CABG to on-pump CABG. Its resultswill lead to a better understanding of the safety and efficacy of off-pump CABG. (Am Heart J 2012;163:1-6.)

Micronized purified flavonoid fraction in pretreating CABG patients.

The aim of the present study was to determine whether oral pretreatment with micronized purified flavonoid fraction (Daflon) has beneficial effects on cardiac function and outcome after cardiac operations. This prospective, randomized trial enrolled 43 patients who had an impaired preoperative left ventricular ejection fraction of less than 0.50 (mean, 0.45 +/- 0.04) and a mean New York Heart Association functional class status of 2.30 +/- 0.74; all were scheduled for elective coronary artery bypass grafting. Patients who were randomized to the Daflon group (n=21) received oral Daflon 500 mg (6 tablets daily for 4 days, followed by 2 tablets for 3 days) preoperatively. Outcome variables included perioperative hemodynamic data, inotropic requirements, morbidity, and death, as well as cardiac ischemia and various outcome markers. Hemodynamic and biochemical data were collected before induction of anesthesia, perioperatively before starting cardiopulmonary bypass, immediately after bypass, and at the 24th postoperative hour. There was only 1 death (in the Daflon group). During the post-cardiopulmonary bypass period, troponin I and lactate dehydrogenase levels were significantly lower in the Daflon group. Also, the New York Heart Association status of the patients in the Daflon group was significantly lower postoperatively. Differences between the 2 groups in lengths of stay in the intensive care unit and hospital, inotropic requirements, and left ventricular ejection fraction levels did not reach statistical significance. Orally administered Daflon might provide better outcomes for patients who have impaired cardiac function before undergoing cardiac operations that require cardiopulmonary bypass.

Timing of induction of cardiomyocyte differentiation for in vitro cultured mesenchymal stem cells: a perspective for emergencies.

Mesenchymal stem cells (MSCs) have the capacity to differentiate into osteoblasts, chondrocytes, adipocytes, myocytes, and cardiomyocytes. Several established methods are presently available for in vitro isolation of MSCs from bone marrow. However, the duration necessary to culture them can be a major handicap to cell-based therapies needed for such urgent cardiovascular conditions as acute myocardial infarction and acute hindlimb ischemia. The best timing of cardiomyocyte differentiation induction after MCS isolation and expansion is still an unresolved issue. Our goal was to investigate the possibility of obtaining functional cardiomyocytes from rat MSC within a shorter time period. We examined MSCs' colony-forming capacity, CD90 and CD34 immunoreactivity during the 14 days of culturing. Cardiomyocyte differentiation was induced by 5-azacytidine. Immunohistochemic staining, together with intracellular Ca2+ measurement experiments, revealed that MSCs do not differentiate into any specific cell lineage but show the characteristics of MSCs on both the 9th and 14th days of the culture. To check the potential for differentiation into cardiomyocytes, experiments with caffeine application and depolarization with KCl were performed. The cells possessed some of the specific biochemical features of contracting cells, with slightly higher capacities on the 14th day. Cells from 9th and 14th days of the culture that were treated with 5-azacytidine had a higher expression of cardiac-specific markers such as troponin I, alpha-sarcomeric actin, and MEF2D compared with the control groups. This study illustrates that it is possible to get functional cardiomyocytes from in vitro MSC culture in a shorter time period than previously achieved. This reduction in time may provide emergency cases with access to cell-based therapies that may have previously been unavailable.

Comparison of different needle diameters and flow rates on bone marrow mononuclear stem cell viability: an ex vivo experimental study.

Considerable information is available regarding the experimental and clinical applications of bone marrow derived stem cells (BMDSC) for regenerative medicine. Optimized stem cell delivery systems might help to maintain better stem cell viability. We have investigated whether needle diameters and flow rates through the needles cause any difference in terms of BMDSC viability.

Off-pump coronary artery bypass graft surgery after stent implantation in a patient with combined thrombophilic risk factors.

The case of coronary artery bypass graft surgery in a 51-year-old woman with a heterozygous form of factor V Leiden, prothrombin mutation G20210A and tumour necrosis factor-alpha -308 G-A associated with high lipoprotein(a) and homocysteinemia levels, as well as elevated factors VIIIc and IX, is presented. She suffered from recurrent episodes of venous thromboembolism and left anterior descending artery subtotal occlusion eight months after percutaneous transluminal coronary angioplasty and stent implantation.

First pulmonary valve replacement with Freedom Solo stentless valve in an adolescent. A case report.

Tetralogy of Fallot (TOF) is a common form of cyanotic heart disease. Complete surgical correction in younger age group offers good long-term results with reasonable morbidity and improved prognosis in patients with TOF. However, following corrective surgery pulmonary valve replacement (PVR) might be required for residual pulmonary regurgitation in order to avoid irreversible right ventricular remodeling. Otherwise, residual uncorrected pulmonary regurgitation may lead to right ventricular dilatation, impaired biventricular function, ventricular arrhythmias and limited exercise capacity. We report the first case of Freedom Solo stentless valve (Sorin Group, Saluggia, Italy) implantation in the pulmonary position in an adolescent with severe pulmonary insufficiency 12 years after the repair of TOF. Pericardial stentless valves may be an alternative choice for pulmonary valve replacement to improve right ventricular contractile recovery and remodeling after PVR and may have impact on long-term survival.

Coronary artery bypass grafting ameliorates the decreased plasma adiponectin level in atherosclerotic patients.

Adiponectin functions as an anti-inflammatory and anti-atherogenic factor, and the decreased plasma adiponectin is a risk factor for coronary disease. The aim of this study was to determine the changes in plasma levels of adiponectin, a potential parameter for atherosclerosis, in patients underwent surgical revascularization. We included forty patients with atherosclerosis (age, 58 +/- 9 years; body mass index [BMI] 26.93 +/- 2.3 kg/m(2)) undergoing coronary artery bypass grafting (CABG). Control group consisted of 40 healthy volunteers, matched for age, gender and BMI (age, 56 +/- 6 years; BMI, 26.78 +/- 2.3 kg/m(2)). We measured various parameters, including high sensitive C-reactive protein (hsCRP), homeostasis model assessment-insulin resistance (HOMA-IR) indexes, and adiponectin. The baseline profile of the patients before CABG showed higher levels of serum hsCRP (13.15 +/- 2.40 mg/l vs 3.97 +/- 1.07 mg/l) and HOMA-IR (1.86 +/- 0.30 vs 1.26 +/- 0.33) and lower plasma adiponectin levels (7.02 +/- 2.01 microg/ml vs 25.46 +/- 3.9 microg/ml), compared to controls (p < 0.001 for each parameter). Plasma adiponectin level was increased one month after CABG from the baseline level to 8.67 +/- 2.05 microg/ml(p < 0.001), although the level was still lower than the control value. Thus, postoperative adiponectin level might be helpful for evaluating the progression of atherosclerosis. Moreover, CABG significantly decreased hsCRP to 7.25 +/- 1.89 mg/l and HOMA-IR to 1.59 +/- 0.33, although these levels were higher than the controls. These results suggest that CABG decreases the cardiac risk factors in atherosclerotic patients.

Regenerative medicine for cardiovascular disorders-new milestones: adult stem cells.

Cardiovascular disorders are the leading causes of mortality and morbidity in the developed world. Cell-based modalities have received considerable scientific attention over the last decade for their potential use in this clinical arena. This review was intended as a brief overview on the subject of therapeutic potential of adult stem cells in cardiovascular medicine with basic science findings and the current status of clinical applications. The historical perspective and basic concepts are reviewed and a description of current applications and potential adverse effects in cardiovascular medicine is given. Future improvements on cell-based therapies will likely provide remarkable improvement in survival and quality of life for millions of patients with cardiovascular disorders.

Early clinical experience with the On-X prosthetic heart valve.

The study aimed to assess the performance of the On-X valve (Medical Carbon Research Institute, Austin, TX). Between December 2000 and January 2003 On-X valves were implanted in 400 patients aged 19-85 years (mean: 55.6+/-16), 290 males and 210 females. There were 120 cases of aortic valve replacement (AVR), 258 mitral valve replacement (MVR) and 22 combined aortic and mitral valve replacement (DVR). Additional procedures were performed in 144 patients. Patients were followed up prospectively at 3- to 6-month intervals. Mean follow-up was 38.4+/-11.8 months (maximum 55.6 months). Overall hospital mortality was 3.5%. Freedom from adverse events at 4 years in the study were as follows: thromboembolism, 99.1% for AVR, 98.3% for MVR and 94.7% for DVR patients; thrombosis, 100% for AVR, 99.2% for MVR and 94.7% for DVR; bleeding events, 99.1% for AVR, 99.2% for MVR and 88.8% for DVR; prosthetic endocarditis, 98.2% for AVR, 99.2% for MVR and 94.7% for DVR. Overall survival at 4 years was 92+/-1%. At echocardiographical examination within 1 year of the AVR, the mean aortic valve gradient was 12.8+/-6, 10.3+/-3, 9.0+/-4, 8.3+/-3, and 6.2+/-3 mmHg for 19, 21, 23, 25, 27/29 mm valve sizes, respectively. MVR mean gradient was 4.9+/-2, 4.5+/-1.2 and 4.0+/-0.8 mmHg for 25, 27/29, 31/33 mm valve sizes, respectively. On-X valve is a highly effective mechanical valve substitute with low morbidity and mortality and good functional results.