Raising the bar to ultradisciplinary collaborations in management of chronic thromboembolic pulmonary hypertension.

Chronic thromboembolic pulmonary hypertension is an underdiagnosed and potentially fatal subgroup of pulmonary hypertension, if left untreated. Clinical signs include exertional dyspnea and non-specific symptoms. Diagnosis requires multimodality imaging and heart catheterization. Pulmonary endarterectomy, an open heart surgery, is the gold standard treatment of choice in selected patients in specialized centers. Targeted medical therapy and balloon pulmonary angioplasty can be effective in high-risk patients with significant comorbidities, distal pulmonary vascular obstructions, or recurrent/persistent pulmonary hypertension after pulmonary endarterectomy. Currently, there is a limited number of data regarding novel coronavirus-2019 infection in patients with chronic thromboembolic pulmonary hypertension and the changing spectrum of the disease during the pandemic. Challenging times during this outbreak due to healthcare crisis and relatively higher case-fatality rates require convergence; that is an ultradisciplinary collaboration, which crosses disciplinary and sectorial boundaries to develop integrated knowledge and new paradigms. Management strategies for the "new normal" such as virtual care, preparedness for further threats, redesigned standards and working conditions, reevaluation of specific recommendations, and online collaborations for optimal decisions for chronic thromboembolic pulmonary hypertension patients may change the poor outcomes.

Iloprost as an acute kidney injury-triggering agent in severely atherosclerotic patients.

BACKGROUND: Iloprost, a stable prostacyclin analog, is used as a rescue therapy for severe peripheral arterial disease (PAD). It has systemic vasodilatory and anti-aggregant effects, with severe vasodilatation potentially causing organ ischaemia when severe atherosclerosis is the underlying cause. In this study, we retrospectively analysed renal outcomes after iloprost infusion therapy in 86 patients. METHODS: Eighty-six patients with PAD who received iloprost infusion therapy were retrospectively analysed. Clinical and biochemical parameters were recorded before (initial, Cr1), during (third day, Cr2), and after (14th day following the termination of infusion therapy, Cr3) treatment. Acute kidney injury (AKI) was defined according to KDIGO guidelines as a ≥ 0.3 mg/dl (26.52 µmol/l) increase in creatinine levels from baseline within 48 hours. RESULTS: Cr2 (1.46 ± 0.1 mg/dl) (129.06 ± 8.84 µmol/l) and Cr3 (1.53 ± 0.12 mg/dl) (135.25 ± 10.61 µmol/l) creatinine levels were significantly higher compared to the initial value (1.15 ± 0.6 mg/dl) (101.66 ± 53.04 µmol/l). AKI was observed in 36 patients (41.86%) on the third day of iloprost infusion. Logistic regression analysis revealed smoking and not using acetylsalicylic acid as primary predictors (p = 0.02 and p = 0.008, respectively) of AKI during iloprost treatment. On the third infusion day, patients' urinary output significantly increased (1813.30 ± 1123.46 vs 1545.17 ± 873.00 cm3) and diastolic blood pressure significantly decreased (70.07 ± 15.50 vs 74.14 ± 9.42 mmHg) from their initial values. CONCLUSION: While iloprost treatment is effective in patients with PAD who are not suitable for surgery, severe systemic vasodilatation can cause renal ischaemia, resulting in nonoliguric AKI. Smoking, no acetylsalicylic acid use, and lower diastolic blood pressure are the clinical risk factors for AKI during iloprost treatment.

Risk factors for postoperative arrhythmia in patients with physiologic univentricular hearts undergoing Fontan procedure.

OBJECTIVE: Advanced age, dilated right atrium, increased preoperative pulmonary artery pressure, increased right atrial pressure, technique of operation, and poor ventricular function were reported to be risk factors for postoperative arrhythmia. Aim of this study is to determine the risk factor for postoperative arrhythmia after Fontan operation with regard to ventricle dominancy and hemodynamic parameters. METHODS: In this retrospective study, the data of the patients including age, weight, dominant ventricle, type of cardiac anomaly, previous operations, duration of cardiopulmonary bypass (CPB), duration of aortic clamping, cardiac rhythm, pulmonary artery pressure, the Nakata Index, systemic atrioventricular (AV) valve insufficiency were obtained from the hospital records, the echocardiographic files, and cardiac catheterization records. Patients were assigned to dominant left ventricle or dominant right ventricle groups. Statistical analysis was performed using the Mann-Whitney U test. RESULTS: Arrhythmia was observed in 21 (52.5%) patients in the postoperative period. No postoperative arrhythmia was observed in patients with a right atrial pressure of <5 mmHg, whereas postoperative arrhythmias were observed in patients with a right atrial pressure of ≥5 mmHg (p<0.05). When the effects of preoperative and postoperative pulmonary artery pressures on postoperative arrhythmia were evaluated, postoperative arrhythmia was determined in only 2 (12.5%) of 8 patients with a preoperative mean pulmonary artery pressure of ≤9 mmHg, whereas postoperative arrhythmia was observed in 19 (59.3%) of 32 patients with a preoperative pulmonary artery pressure of ≥10 mmHg. A preoperative mean pulmonary artery pressure of >10 mmHg increased the risk of postoperative arrhythmia (p<0.02). Postoperative arrhythmia was determined in 8 (53%) of 15 patients with a dominant right ventricle, and in 13 (52%) of 25 patients with a dominant left ventricle (p>0.05). CONCLUSION: While a preoperative mean pulmonary artery pressure of >10 mmHg and a preoperative right atrial pressure of >5 mmHg were the risk factors for postoperative arrhythmia in patients undergoing Fontan procedure, the right or left ventricular dominance was not a risk factor.

Devascularization of head and neck paragangliomas by direct percutaneous embolization.

Preoperative transarterial embolization of head and neck paragangliomas using particulate agents has proven beneficial for decreasing intraoperative blood loss. However, the procedure is often incomplete owing to extensive vascular structure and arteriovenous shunts. We report our experience with embolization of these lesions by means of direct puncture and intratumoral injection of n-butyl cyanoacrylate (NBCA) or Onyx. Ten patients aged 32-82 years who were referred for preoperative embolization of seven carotid body tumors and three jugular paragangliomas were retrospectively analyzed. Intratumoral injections were primarily performed in four cases with multiple small-caliber arterial feeders and adjunctive to transarterial embolization in six cases with incomplete devascularization. Punctures were performed under ultrasound and injections were performed under roadmap fluoroscopic guidance. Detailed angiographies were performed before and after embolization procedures. Control angiograms showed complete or near-complete devascularization in all tumors. Three tumors with multiple small-caliber arterial feeders were treated with primary NBCA injections. One tumor necessitated transarterial embolization after primary injection of Onyx. Six tumors showed regional vascularization from the vasa vasorum or small-caliber branches of the external carotid artery following the transarterial approach. These regions were embolized with NBCA injections. No technical or clinical complications related to embolization procedures occurred. All except one of the tumors were surgically removed following embolization. In conclusion, preoperative devascularization with percutaneous direct injection of NBCA or Onyx is feasible, safe, and effective in head and neck paragangliomas with multiple small-caliber arterial feeders and in cases of incomplete devascularization following transarterial embolization.

Bentall procedure for the treatment of aortic dissection after cardiac transplant: a case report.

Aortic dissection affecting the donor aorta after cardiac transplant is a rarely seen complication. Data on the literature about the subject is restricted to case reports. Here, we present a case of type A aortic dissection after cardiac transplant that was successfully treated by the Bentall procedure.

Mitral valve replacements in redo patients with previous mitral valve procedures: mid-term results and risk factors for survival.

OBJECTIVE: We aimed to investigate the risk factors for hospital mortality, short (five years) and mid-term (10 years) survival in patients who underwent mitral valve replacements in redo patients with previous mitral valve procedures. PATIENTS AND METHODS: Between September 1989 and December 2003, 62 redo patients have undergone mitral valve replacements due to subsequent mitral valve problems. Preoperative, operative, and postoperative data were analyzed retrospectively and evaluated for risk factors affecting hospital mortality, mid- and long-term survival. RESULTS: The hospital mortality was 6.4%. The one-, five-, and 10-year actuarial survival rates were 94%+/- 2%, 89%+/- 6%, and 81 +/- 9%. New York Heart Association (NYHA) functional class IV, low left ventricular ejection fraction (<35%), increased left ventricular end-diastolic diameter (LVEDD) > 50 mm, female gender, pulmonary edema, and urgent operations were found to be risk factors in short-term survival. NYHA functional class IV, low left ventricular ejection fraction, increased LVEDD, and increased left atrial diameter (LA > 60 mm) were risk factors in mid-term survival. CONCLUSION: Redo mitral valve surgery with mechanical prosthesis offers encouraging short- and mid-term survival. NYHA functional class IV, low left ventricular ejection fraction, and increased left ventricular diameters were especially associated with increased short- and mid-term mortality. Earlier surgical management before the development of severe heart failure and myocardial dysfunction would improve the results of redo mitral valve surgery.

Endovascular therapy for thoracic and abdominal aortic emergencies.

BACKGROUND: Emergent situations of both the thoracic and abdominal aortae are serious life-threatening situations. Endovascular stent graft repair offers an alternative to conventional operation for management of aortic diseases. Our aim was to report our experience with endovascular stent graft repair of thoracic and abdominal aortic emergencies. METHODS: Between April 2004 and March 2007, endovascular stent graft repair was performed in 16 patients (13 males, 3 females; mean age 61.4+/-16.3; range 38 to 86 years). The emergent lesions were in the thoracic aorta in 8 patients and abdominal aorta in the remainder. The deployed stent graft systems were Talent-Medtronic (n=8) and Excluder-Gore (n=8). RESULTS: Successful deployment of the stent grafts in the appropriate position was achieved in all patients. Hospital mortality occurred in 3 patients. There was no conversion to open surgery. The total number of endoleaks was 3 (18.75%). CONCLUSION: Endovascular stent graft placement is a feasible and effective approach in the emergency treatment of patients with complicated emergent pathologies of both thoracic and abdominal aortae.

Regional anesthesia in elderly patients undergoing carotid surgery: report of a case series.

BACKGROUND: This study evaluates the short-term results in patients more than 75 years of age undergoing carotid endarterectomy at a single institution. METHODS: Between June 2004 and June 2007, carotid endarterectomy operations were performed in 123 patients. A total of 70 patients had regional anesthesia. The data for all patients were retrospectively reviewed. Regional anesthesia and selective shunting was performed in all patients. RESULTS: In 6 patients, a shunt was required. Primary closure of the carotid artery was performed in 22 patients and patch angioplasty was used in the remainder. There were no postoperative neurological complications. One patient died due to myocardial infarction. CONCLUSIONS: Carotid endarterectomy with regional anesthesia can be performed safely in the elderly population with low mortality and morbidity. Regional anesthesia may have advantages over general anesthesia and could potentially aid in avoiding complications related to shunt use.

The role of antiendothelial cell antibodies in the development and follow-up of coronary and peripheral arterial diseases.

Occlusive lesions in the arterial endothelium are often caused by formation of intimal hyperplasia and fibrinoid necrosis. The objective of this study was to investigate the association between antiendothelial cell antibodies (AECAs) and the development of coronary artery disease (CAD) and peripheral artery disease (PAD). In this study, 94 patients with CAD or PAD and 94 healthy volunteers serving as control subjects were examined. Frozen sections of human umbilical vein endothelial cells and primate smooth muscle cells were used to detect the presence of AECAs, which were found in 52 of 94 patients (55%) and in 15 of 94 controls (16%) (P < .001). Endothelial structure tissue damage is a major factor in arterial diseases. In the present study, a statistically significant relationship was found between AECAs and the development of CAD and PAD. The presence of AECAs has been identified as a risk factor for these diseases. According to this study, AECAs are reliable prognosticators for the development of CAD and PAD. Further studies with large numbers of serum samples are under way.

Coronary bypass surgery in kawasaki disease in a four-year-old patient: case report.

Kawasaki disease is an acute vasculitis syndrome of unknown etiology that mainly affects small and medium-sized arteries, particularly the coronary arteries. This disease is rarely seen in infants and young people in Turkey. In this short report, we present a four-year-old patient who has Kawasaki disease associated with coronary artery aneurysm and underwent coronary bypass grafting.

Atherosclerosis of radial and internal thoracic arteries used in coronary bypass: atherosclerosis in arterial grafts.

BACKGROUND: This study aimed to evaluate the degree and incidence of atherosclerosis in internal thoracic (ITA) and radial arteries (RA) harvested for coronary bypass grafting. MATERIALS AND METHODS: The association of major clinical events and etiological factors for atherosclerosis was investigated in 770 arterial segments obtained prospectively from 480 patients. Potential risk factors for atherosclerosis were age, gender, smoking, diabetes mellitus, peripheral vascular disease, cerebrovascular disease, chronic renal failure, hypercholesterolemia, obesity, hypertension, and a positive family history. RESULTS: Six types of histological lesions have been defined; grade III or more was present in the RA in 47 (16%) patients and in the ITA in 30 (7%). The mean grade was 1.6 +/- 0.6 in the ITA and 2.1 +/- 0.9 in the RA (p < 0.001). CONCLUSION: RA had a significantly greater prevalence of atherosclerosis than the same patients' ITA. There was a strong correlation between ITA atherosclerosis and age. The presence of calcification may lead surgeons to avoid an extra incision according to risk factors, although most of these are not predictive.

[Traumatic aneurysm of the superficial temporal artery: a case report]. / Travmatik süperfisyel temporal arter anevrizmasi: Olgu sunumu.

Superficial temporal artery (STA) aneurysm is rare and usually caused by trauma. In this report, a 23-year-old man who had a left STA pseudoaneurysm which was secondary to blunt trauma and its surgical treatment was presented. A patient was admitted to our clinic with the complaints of a bulge in the left temporal location that had developed almost a month ago subsequent to a fall and headache. We discovered a pulsatile mass, with 1.5 x 1.5 cm in size, at the left temporal region, on the physical examination. Neurological examination was normal. Angiography revealed pseudoaneurysm originating from superficial temporal artery. Under local anesthesia, temporal artery ligation and aneurysmectomy were performed. Postoperative course was uneventful.

Triple-valve procedures: impact of risk factors on midterm in a rheumatic population.

BACKGROUND: We aimed to determine the influence of preoperative, intraoperative, and postoperative variables on short and midterm results in patients undergoing triple-valve surgery. METHODS: Between September 1989 and December 2003, 157 patients underwent triple-valve surgery with mechanical prosthetic valves. Preoperative, operative, and postoperative data were retrospectively analyzed and risk factors affecting hospital mortality and short and midterm survival were evaluated. RESULTS: The hospital mortality was 2.5%. Multivariate analysis revealed that New York Heart Association functional class IV, low left ventricular ejection fraction (< 0.35) and increased left ventricular end diastolic diameter (> 50 mm Hg) were associated with increased short and midterm mortality. The freedom rate from reoperation and thromboembolic complications at 5 years were 93% +/- 4% and 81% +/- 7%, respectively. In echocardiographic assessments, significant decrease in left ventricular end-diastolic and end-systolic diameters (53.1 +/- 8.3 vs 50.1 +/- 7.1, p = 0.002 and 35.3 +/- 7.4 vs 32.6 +/- 7.2, p = 0.002) was observed. CONCLUSIONS: Triple-valve surgery offers satisfactory short and midterm results and prevents ventricular dilatation. Mortality significantly decreases if surgery is performed before left ventricle functions deteriorate.

Diaphragmatic paralysis after cardiac surgery in children: incidence, prognosis and surgical management.

Diaphragmatic paralysis (DP) after cardiac surgery is an important complication especially in infants. We analyzed the incidence, clinical course, surgical management and follow up of the patients with DP, retrospectively. Between 1996 and 2005, 3,071 patients underwent cardiac surgery. Total number of patients with DP was 152 (4.9%). Out of 152 patients, 42 were surgically treated with transthoracic diaphragm plication (1.3%). The overall incidence of diaphragm paralysis was higher in correction of tetralogy of Fallot (31.5%), Blaloc-Taussig (B-T) shunt (11.1%) and VSD closure with pulmonary artery patch plasty (11.1). The incidence of DP which require plication was higher in B-T shunt (23.8%) arterial switch (19%) and correction of tetralogy of Fallot (11.9%). Mean and median age at the time of surgery were 17.8 +/- 3.6 and 6 months, respectively. Median time from cardiac surgery to surgical plication was 12 days. Indications for plication were repeated reintubations (n = 22), failure to wean from ventilator (n = 12), recurrent lung infections (n = 5) and persistent respiratory distress (n = 3). Mortality rate was 19.1%. Being under 1 year of age, pneumonia and plication 10 days after mechanical ventilation were associated with higher incidence mortality (P < 0.05). Phrenic nerve injury is a serious complication of cardiac surgery. It is more common after some special procedures. Spontaneous recovery is very rare. Being under 1 year of age, plication after 10 days from the surgery and pneumonia are major risk factors for mortality even in plicated patients. Transthoracic plication is helpful if performed early.

Successful surgical treatment of massive pulmonary embolism after coronary bypass surgery.

Acute massive pulmonary embolism after cardiac surgery is very rare. Although accurate diagnosis and rapid treatment are crucial to a successful outcome, there is no standard treatment option. Thrombolytic therapy and catheter embolectomy are the usual treatment options, but they are associated with risks, especially in patients who experience massive pulmonary embolism after coronary artery bypass surgery. Open pulmonary embolectomy may be the best choice for treating these patients. This report describes our use of emergency pulmonary embolectomy along with cardiopulmonary bypass as an effective therapeutic approach in 2 cases of massive pulmonary embolism that occurred after on-pump coronary artery bypass grafting.

Ventricular arrhythmia and tetralogy of Fallot repair with transannular patch.

OBJECTIVE: Life-threatening arrhythmias and sudden death remain to be serious late complications after correction of tetralogy of Fallot. The aim of this study was to detect ventricular arrhythmia incidence and to find out the relationship between ventricular arrhythmia and the transannular and infundibular patch repair techniques to correct tetralogy of Fallot. That is still unpredictable exactly. METHODS: Thirty-nine patients with mean age of 12.1+/-3.1 years were studied prospectively for 7.1+/-2.1 years after operation. They were all investigated with electrocardiography, echocardiography, treadmill and Holter monitorization. Right ventricular functions, exercise capacity and arrhythmia patterns were assessed. Lown criteria were used for grading the arrhythmia patterns. QRS duration, QT dispersion and QT dispersion indexes were calculated. RESULTS: Follow up time was 5 to 13 years in both groups. All QT dispersion times and indexes were within normal ranges and there were no differences between two groups. Holter and treadmill studies did not reveal during any ventricular arrhythmia risk in the study and control groups. CONCLUSION: Seven years of follow-up after correction of tetralogy of Fallot revealed that transannular patch reconstruction is not a cause of tendency for ventricular arrhythmia according to Lown criteria, QT dispersion, QT dispersion indexes and QRS duration do support the results of previous studies.

Valve replacement surgery in patients with end-stage renal disease: long-term results.

BACKGROUND: The life expectancy of patients with chronic renal failure who are dependent on dialysis is very poor. This study was undertaken to determine time-related outcomes in dialysis patients requiring cardiac valve replacement. METHODS: From 1994 to 2001, 29 end-stage renal disease (ESRD) patients on hemodialysis (HD) program underwent 30 valve replacement operations: 29 received mechanical valves (97%), and one received bioprosthetic valves. The sites of valve replacement were 11 aortic (36.7%), 18 mitral (60%), and one both aortic and mitral (3.3%). Mean age was 42.46 +/- 14.26 years (range 17-75 years). Follow-up was completed in 28 patients (96.5%). RESULTS: Early postoperative mortality (in the first 30 days) was 3.4% (n = 1). The overall estimated Kaplan-Meier survival was 56.7% at 36 months, 46.7% at 60 months, and 43.3% at 96 months. HD program was discontinued for two patients after renal transplantation in the follow-up period. All patients, except the one with bioprosthesis, used warfarin sodium for anticoagulation and none of them had bleeding. One of the patients had a major cerebrovascular accident (CVA) and another one had a minor CVA at the follow-up (6.7%). CONCLUSIONS: Life quality is better and life expectancy is longer after valve replacement in ESRD patients who have valvular disease. Also, longer life expectancy increases the probability for finding donors for kidney transplantation.