An overlooked fact: thrombocytopenia following bioprosthetic aortic valve replacement.

INTRODUCTION: Thrombocytopenia observed after bioprosthetic aortic valve replacement has remained a puzzle to solve. AIM: To analyze thrombocytopenia occurring after bioprosthetic aortic valve replacement by comparison to mechanical aortic valve replacement and coronary artery bypass grafting procedures. MATERIAL AND METHODS: The study was conducted retrospectively on a total of 297 patients who underwent bioprosthetic aortic valve replacement, mechanical prosthetic aortic valve replacement and coronary artery bypass grafting at the cardiovascular surgery department of our clinical center between January 2013 and September 2017. Preoperative and postoperative first 14-day thrombocyte levels of the patients were analyzed. RESULTS: The postoperative blood thrombocyte level decrease was found to be more significant in patients who underwent bioprosthetic aortic valve replacement than in patients who underwent mechanical aortic valve replacement and coronary artery bypass grafting (p < 0.01). There was also a statistically significant difference in the time to reach the lowest postoperative platelet levels according to type of surgery (p = 0.001; p < 0.01). CONCLUSIONS: When compared to the patients who underwent coronary artery bypass grafting and mechanical prosthetic aortic valve replacement, postoperative thrombocytopenia was found to be more severe in patients who underwent bioprosthetic aortic valve replacement, with a dramatic decrease in thrombocyte count being observed on the postoperative second day. It was found that the thrombocytopenia recovers without causing any problem. We think that the shear forces may play a role in this recovery through washout of chemicals responsible for thrombocytopenia from the glutaraldehyde treated bioprostheses.

The importance of mass diameter in decision-making for preoperative coronary angiography in myxoma patients.

OBJECTIVES: Although coronary angiography (CAG) is generally performed to rule out coexisting coronary artery disease in patients with cardiac myxoma, its necessity to evaluate vascular supply of the myxoma is debatable. The aim of this article is to evaluate clinical experience and CAG findings in our patient group. METHODS: This retrospective analysis was performed in 46 patients (17 men, mean age 57.7 ± 8.6 years), who underwent surgery with an indication for cardiac myxoma between 2004 and 2016 with a CAG performed preoperatively. All CAGs were evaluated in a blinded manner by a cardiac surgeon and a cardiologist separately. Correlations between the presence and pattern of feeding vessels, presence of an arteriocavity fistula (ACF), coronary arterial dominance, size of mass and clinical presentations were analysed. RESULTS: Coronary artery disease defined as >50% obstructive lesions was detected in 10 patients (21.7%). The tumour diameter was found to be significantly higher in patients who had an ACF and a dual-feeding artery (P = 0.049 and P = 0.0001, respectively). Additionally, there was a significant relationship between the presence of dual-feeding vessels and ACF (P = 0.014). ROC analysis revealed a cut-off point of 27 mm in diameter based on the presence of an ACF and a dual-feeding artery. In cases with a diameter of 27 mm or above, the risk of existence of an ACF was 4.68-fold greater, with a confidence interval of 95%, and a dual-feeding pattern was seen in all of them. CONCLUSIONS: This study suggests that preoperative CAG can be considered to detect feeding vessels that may lead to a steal phenomenon, which may alter the management in patients with myxoma greater than 27 mm in diameter.

Which method to use for surgical ablation of atrial fibrillation performed concomitantly with mitral valve surgery: radiofrequency ablation versus cryoablation

Abstract Objective: The effects of energy source on the maintenance of sinus rhythm and the contribution of demographic characteristics to the case selection in patients submitted to ablation performed concurrently with mitral valve surgery were analyzed. Methods: Cryothermal (n=42; 43.8%) and radiofrequency (n=54; 56.3%) energy were employed in 96 patients submitted to mitral valve replacement and Cox maze IV procedure. Patients were called for control visits between 15 days and 12 months after discharge. The causal relationship between recurrence of atrial fibrillation and factors such as left atrial diameter, C-reactive protein, hypertension, left ventricular ejection fraction, chronic obstructive pulmonary disease, and body mass index was determined. Results: Maintenance rates of the sinus rhythm with radiofrequency and cryoablation were 97.6% and 96.3%, respectively, in the first postoperative month, whereas at the 12th postoperative month were 88.1% and 83.3%. No significant difference was found between groups in relation to the energy source. Sensitivity and specificity for left atrial diameter with a cut-off value of 50.5 mm were 85.7% and 70.7%, respectively. Sensitivity and specificity for C-reactive protein with a cut-off value of 12 mg/dL on the 15th postoperative day were 83.3% and 88.9%, respectively. The effect of body mass index on atrial fibrillation recurrence was 3.2 times. Sensitivity and specificity for left ventricular ejection fraction 37% cut-off value were 96.3% and 11.4%, respectively. Atrial fibrillation in hypertensive cases was 5.3 times more. In patients with chronic obstructive pulmonary disease, recurrence of atrial fibrillation was 40%. The causal relation between recurrence of atrial fibrillation and the studied factors was established. Conclusion: Demographic characteristics have a significant impact on ablation efficiency, while the type of energy source does not.

Is Preoperative Clopidogrel Resistance a Predictor of Bleeding and Risks in Patients Undergoing Emergency CABG Surgery?

OBJECTIVE: The aims of this study were to determine whether the detection of preoperative clopidogrel resistance in patients undergoing cardiac surgery while using clopidogrel could play a guiding role in the prediction of postoperative excessive bleeding, transfusion requirements, and risks and to provide clinically significant data. METHODS: Two hundred and twenty-two patients [median age: 59.4 (38-83) years; 38 females] undergoing emergency and elective coronary artery bypass graft (CABG) surgeries in our clinic were evaluated prospectively. Patients with multiple systemic diseases, other than diabetes mellitus (DM) and hypertension (HT), were excluded. Patients receiving clopidogrel were also evaluated for clopidogrel resistance and grouped according to the results of this test. Assessments of platelet functions were performed by multiplate impedance aggregometry method and adenosine diphosphate test. RESULTS: The use of postoperative fresh blood replacement and platelet transfusion was higher in patients receiving clopidogrel than in those not receiving it (P=0.001, P=0.018). DM, HT, myocardial infarction, and the number of presentation to the emergency room were significantly higher in patients receiving clopidogrel than in those not receiving it (P<0.05). No significant difference was determined between patients with and without clopidogrel resistance regarding the amount of bleeding during and after surgery, erythrocyte suspension and fresh-frozen plasma transfusion rates, preoperative troponin values, ejection fraction values, and length of hospital stays (P>0.05). CONCLUSION: We think that resistance studies in patients receiving clopidogrel before cardiac surgery are not efficient to predict bleeding and bleeding-related complications in patients undergoing emergency and elective CABG surgeries.

Is preoperative clopidogrel resistance a predictor of bleeding and risks in patients undergoing emergency cabg surgery?

Abstract Objective: The aims of this study were to determine whether the detection of preoperative clopidogrel resistance in patients undergoing cardiac surgery while using clopidogrel could play a guiding role in the prediction of postoperative excessive bleeding, transfusion requirements, and risks and to provide clinically significant data. Methods: Two hundred and twenty-two patients [median age: 59.4 (38-83) years; 38 females] undergoing emergency and elective coronary artery bypass graft (CABG) surgeries in our clinic were evaluated prospectively. Patients with multiple systemic diseases, other than diabetes mellitus (DM) and hypertension (HT), were excluded. Patients receiving clopidogrel were also evaluated for clopidogrel resistance and grouped according to the results of this test. Assessments of platelet functions were performed by multiplate impedance aggregometry method and adenosine diphosphate test. Results: The use of postoperative fresh blood replacement and platelet transfusion was higher in patients receiving clopidogrel than in those not receiving it (P=0.001, P=0.018). DM, HT, myocardial infarction, and the number of presentation to the emergency room were significantly higher in patients receiving clopidogrel than in those not receiving it (P<0.05). No significant difference was determined between patients with and without clopidogrel resistance regarding the amount of bleeding during and after surgery, erythrocyte suspension and fresh-frozen plasma transfusion rates, preoperative troponin values, ejection fraction values, and length of hospital stays (P>0.05). Conclusion: We think that resistance studies in patients receiving clopidogrel before cardiac surgery are not efficient to predict bleeding and bleeding-related complications in patients undergoing emergency and elective CABG surgeries.

Valve repair to avoid prosthetic valve pathology: Mid-term results in mitral valve repair.

BACKGROUND: In this study, we aimed to present our results of mitral valve repair. METHODS: Between January 2007 and November 2016, a total of 128 patients (72 males, 56 females; mean age 51.8±17.2 years; range 16 to 84 years) who underwent mitral valve repair in our heart center were retrospectively analyzed. There were mitral regurgitation in 86.7% (n=111), mitral stenosis in 7.8% (n=10), and mixed type valve disease in 5.5% of the patients (n=7). Mitral ring annuloplasty was performed in 80.5% (n=103), implantation of the artificial chordae in 36.7% (n=47), open mitral commissurotomy in 13.3% (n=17), and Alfieri procedure in 6.3% (n=8) of the patients. Sixty-two patients (48.8%) underwent isolated mitral valve repair, while concomitant surgical procedures were performed in the remaining patients. Postoperative mean follow-up was 52 months. RESULTS: Early (30-day) mortality was observed in seven patients due to low cardiac output. There was no mid-term mortality. During follow-up, various degree of mitral regurgitation was detected in 4 patients (3.6%), regurgitation was severe in two of them and these two require reoperation with the replacement of the valve. Patients with a myxomatous valve pathology who underwent isolated valve repair most benefited from valve repair. Patients with isolated mitral stenosis were the most successful group among the patients with a rheumatic etiology. Postoperative echocardiography showed a significant decrease in the left atrial diameter and pulmonary artery systolic pressures (p<0.01). CONCLUSION: Mitral valve repair can be applied as an effective and safe treatment method in patients in whom the mitral valve anatomy is sufficient for repair. We suggest that each patient with mitral valve pathology should be evaluated in terms of reparability.

Which Method to Use for Surgical Ablation of Atrial Fibrillation Performed Concomitantly with Mitral Valve Surgery: Radiofrequency Ablation versus Cryoablation.

OBJECTIVE: The effects of energy source on the maintenance of sinus rhythm and the contribution of demographic characteristics to the case selection in patients submitted to ablation performed concurrently with mitral valve surgery were analyzed. METHODS: Cryothermal (n=42; 43.8%) and radiofrequency (n=54; 56.3%) energy were employed in 96 patients submitted to mitral valve replacement and Cox maze IV procedure. Patients were called for control visits between 15 days and 12 months after discharge. The causal relationship between recurrence of atrial fibrillation and factors such as left atrial diameter, C-reactive protein, hypertension, left ventricular ejection fraction, chronic obstructive pulmonary disease, and body mass index was determined. RESULTS: Maintenance rates of the sinus rhythm with radiofrequency and cryoablation were 97.6% and 96.3%, respectively, in the first postoperative month, whereas at the 12th postoperative month were 88.1% and 83.3%. No significant difference was found between groups in relation to the energy source. Sensitivity and specificity for left atrial diameter with a cut-off value of 50.5 mm were 85.7% and 70.7%, respectively. Sensitivity and specificity for C-reactive protein with a cut-off value of 12 mg/dL on the 15th postoperative day were 83.3% and 88.9%, respectively. The effect of body mass index on atrial fibrillation recurrence was 3.2 times. Sensitivity and specificity for left ventricular ejection fraction 37% cut-off value were 96.3% and 11.4%, respectively. Atrial fibrillation in hypertensive cases was 5.3 times more. In patients with chronic obstructive pulmonary disease, recurrence of atrial fibrillation was 40%. The causal relation between recurrence of atrial fibrillation and the studied factors was established. CONCLUSION: Demographic characteristics have a significant impact on ablation efficiency, while the type of energy source does not.

The effects of the metabolic syndrome on coronary artery bypass grafting surgery.

BACKGROUND: The metabolic syndrome (MS) is a clustering of factors that are associated with increased cardiovascular risk. A low-grade inflammatory process acts as the underlying pathophysiology, which suggests that the MS may have a detrimental effect on coronary interventions, including coronary artery bypass grafting (CABG) surgery performed with cardiopulmonary bypass (CPB). We aimed to evaluate the effect of the MS on morbidity and mortality rates in the early postoperative period in patients undergoing CABG. METHODS: We prospectively included 152 patients (109 males and 43 females; mean age 60.1 ± 8.6 years) who underwent elective CABG on CPB between January and September 2011. Early postoperative morbidity and mortality rates were compared between subjects with and without the MS. Diagnosis of the MS was based on the American National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) criteria. RESULTS: Of the study group, 64 patients (42%) had the MS. The two groups were similar in age and gender. In the postoperative period, rates of atrial fibrillation, wound infection, pulmonary complications, and lengths of intubation, hospitalisation and intensive care unit stay were significantly higher in MS patients (p < 0.01). The MS was significantly associated with wound infection (OR 6.64, 95% CI: 1.72-25.75), pulmonary complications (OR 6.44, 95% CI: 1.58-26.33), arrhythmia (OR 5.47, 95% CI: 1.50-19.97) and prolonged intubation (OR 1.17, 95% CI: 1.05-1.32). The mortality rate was 3.1% in the MS group and 1.1% in the non-MS group, with no significant difference (p > 0.05). CONCLUSION: The MS was associated with a higher rate of early postoperative morbidity following CABG, without having a significant effect on the mortality rate.

The effect of proximal anastomosis on the expansion rate of a dilated ascending aorta in coronary artery bypass surgery: a prospective study.

BACKGROUND: This study was designed to determine the short- and long-term effects of proximal aortic anastomosis, performed during isolated coronary artery bypass grafting (CABG) in patients with dilatation of the ascending aorta who did not require surgical intervention. METHODS: The study was performed on 192 (38 female and 160 male patients; mean age, 62.1 ± 9.2 years; range, 42-80 years) patients with dilatation of the ascending aorta who underwent CABG surgery between 1 June 2006 and 31 May 2014. In group 1 (n = 114), the saphenous vein and left internal mammarian artery grafts were used, and proximal anastomosis was performed on the ascending aorta. In group 2 (n = 78), left and right internal mammarian artery grafts were used, and proximal aortic anastomosis was not performed. Pre-operatively and in the first and third years postoperatively, the ascending aortic diameter was measured and recorded using transthoracic echocardiography at four different regions (annulus, sinus of Valsalva, sinotubular junction and tubular aorta). RESULTS: A statistically significant difference was found between the groups for the number of grafts used and the duration of aortic cross-clamping and cardiopulmonary bypass. No significant intergroup difference was seen for the mean diameter of the ascending aorta (p > 0.05). Annual changes in the aortic diameter were found to be extremely significantly different in both groups (p = 0.0001). Mean values of the aortic diameter at the level of the sinotubular junction and tubular ascending aorta, mean aortic diameters (p = 0.002 and p = 0.0001, respectively), annual increase in diameter (p = 0.0001 and p = 0.0001, respectively), and mean annual difference in diameter (p = 0.0001 and p = 0.0001, respectively) at one and three years postoperatively were statistically significantly different between the groups. CONCLUSION: In patients with ascending aortic dilatation who did not require surgical intervention and who had proximal anastomosis of the ascending aorta and underwent only CABG, we detected statistically significant increases in the diameter of the sinotubular junction and tubular aorta up to three years postoperatively.

Synthesis and evaluation of N-heteroarylsubstituted triazolosulfonamides as carbonic anhydrase inhibitors.

A new series of N-heteroarylsubstituted triazolosulfonamide compounds were synthesized and their inhibitory effects on the activity of purified human carbonic anhydrase (hCA) I and II were evaluated. Compounds (3 a-k) were prepared by propargylation of N-heteroaryl compounds. Compound 5 was obtained from sulfanilamide and sodium nitrite followed by addition of sodium azide. The products (6 a-k) were synthesized from compounds 3 and 5. The results showed that all the synthesized compounds were inhibited the CA isoenzymes activity. Figure 6a (IC50 = 0.52 µM for hCA I and 0.34 µM for hCA II) has the most inhibitory effect among the synthesized compounds.

The role of Porphyromonas gingivalis in the development of atherosclerosis and its relationship with fim A genotype.

BACKGROUND: Porphyromonas gingivalis, a major periodontal pathogen, is gaining increasing attention for its possible association with atherosclerosis. Its fimbriae are classified into six genotypes (Types I-V, Ib) based on the diversity of the fim A genes encoding the fimbrial subunits. In this study, fim A genotype's distribution of P. gingivalis was analyzed in atherosclerotic plaque specimens. METHODS: A total of 50 atherosclerotic plaque specimens and 50 non-atherosclerotic, post stenotic aneurysm specimens were collected from patients undergoing cardiovascular surgery. Bacterial DNA was also extracted from each specimen, as real-time PCR was carried out with P. gingivalis-specific primer sets. The positive specimens of P. gingivalis were further analyzed to discriminate the fim A genotype using real-time and nested PCR methods. RESULTS: P. gingivalis was detected only in one atherosclerotic plaque; however, the genotype was nontypable in this specimen. CONCLUSIONS: We state that it is not easy to show a significant relationship between P. gingivalis, its fim A genotype, and atherosclerosis. We suggest that new extended studies based especially upon the quantitave determination of P. gingivalis and its genotype distribution on atherosclerotic specimens are needed to show an evident relationship between atherosclerosis and P. gingivalis.

Association between endothelial nitric oxide synthase intron 4a/b polymorphism and aortic dissection.

OBJECTIVES: The genetic risk factors that contribute to the risk of developing aortic dissection (AD) have been studied. We assessed the association of endothelial nitric oxide synthase (eNOS) gene polymorphism with AD. STUDY DESIGN: Patients who underwent surgery with the diagnosis of AD and survived after the operation in our center between May 2007 and June 2011 were recruited retrospectively. The eNOS intron 4a/b polymorphism was determined by polymerase chain reaction (PCR) using oligonucleotide primers (sense: 5'-AGGCCCTATGGTAGTGCCTTT-3'; antisense: 5'-TCTCTTAGTGCTGTGGTCAC-3') that flank the region of the 27 bp VNTR in intron 4. RESULTS: Thirty-nine patients (88%) had type A AD, while the remainder (12%) had type B AD. The distribution of eNOS4 a/b gene polymorphism differed significantly from the control group, with higher frequencies of eNOS 4a/a and 4a/b genotypes in the AD group (x(2)=7.16, p=0.03). CONCLUSION: In this study, the distribution of eNOS genotypes differed between the AD and control groups; however, this polymorphism was not found to be an independent factor for the development of AD.

Early and intermediate term results for surgical correction of total anomalous pulmonary venous connection.

BACKGROUND: This retrospective study evaluated factors associated with mortality and morbidity in patients having functionally biventricular heart (FBH) and functionally univentricular heart (FUH) undergoing total anomalous pulmonary venous connection (TAPVC) repair. METHODS: We reviewed medical records retrospectively and identified 72 patients undergoing TAPVC repair between July 2002 and December 2010; and 62 patients had FBH and 10 patients had FUH. The median age and weight at repair was 9.1 months (range, 8 days-16 years) and 6.7 kg (range, 2.5-57 kg). The TAPVC anatomy was supracardiac in 41 (56.9%), cardiac in 18 (25%), infracardiac in eight (11.1%), and mixed in five patients (6.9%). RESULTS: There were seven early deaths (2 FBH [25%] and 5 FUH [62.5%]) and one late death (FUH). Presence of FUH (p < 0.01), heterotaxy syndrome (p = 0.03), young age (p < 0.01), low weight (p < 0.01) and long CPB time (p = 0.04) at the time of surgery were statistically significant risk factors for mortality. Morbidity was related to long duration of postoperative mechanical ventilation, intensive care unit and hospital stay. Presence of FUH was the only significant risk factor for morbidity (p < 0.01). After a mean follow-up of 52.1 months (range, 3-74 months), 59 (92%) of 64 survivors were asymptomatic without any medication, and five have mild symptoms with regular physical activity. CONCLUSION: Operative results of TAPVC have dramatically improved in recent years. However, patients having FUH (especially with concomitant palliative surgery), heterotaxy syndrome, low weight, early age, and long CPB time still have an increased operative mortality.

Computed tomography evaluation of different chest tube sites for residual pleural volumes after coronary artery bypass surgery.

BACKGROUND AND OBJECTIVES: We investigated the efficacy of pleural drainage with the use of different chest tube methods in patients after coronary artery bypass graft (CABG) surgery. DESIGN AND SETTING: Prospective randomized study of 60 patients undergoing elective on-pump single CABG surgery. PATIENTS AND METHODS: The left internal mammary arterial grafts were harvested from all patients. The patients were separated into three groups: In one group (IC6, n=20), pleural tubes were inserted through the sixth intercostal space at the midaxillary line; in the second group (SX-r, n=20), rigid straight pleural tubes were inserted from the mediastinum through the subxiphoid area; and in the third group (SX-s, n=20), soft curved drainage tubes were inserted from the mediastinum through the subxiphoid area. The residual pleural effusion was examined by multislice CT scans within 8 hours of removal of the drainage tubes. Pain was evaluated according to standard methods. RESULTS: The groups did not differ with respect to volume of residual pleural effusion (P >.05). The IC6 group had a higher mean pain score than the other two groups (P <.05), whose mean pain scores did not differ significantly from each other (P >.05). IC6 group patients had a higher requirement for analgesics. The rate of atelectasis was higher in group IC6 (P <.05). CONCLUSION: CT scans revealed that different chest tube insertion sites have the same efficiency for draining of pleural effusion, although drainage tubes inserted through the thoracic cage may result in more severe pain.

Simultaneous operation in a patient with coronary heart disease, abnormal orifice of coronary arteries, morgagni hernia, atrial septal defect, and pericardial and pleural agenesis.

A 68-year-old male patient with acute coronary syndrome was referred to our center. He also received a diagnosis of diaphragmatic hernia after a clinical examination. The patient underwent a simultaneous aorta coronary bypass operation and repair of the congenital diaphragm hernia. During the operation, the patient was observed to have an atrial septal defect. Our handling of the case is discussed in light of the literature.

Is the aortic valve pathology type different for early and late mortality in concomitant aortic valve replacement and coronary artery bypass surgery?

We assessed the effects of aortic valve pathology type on the long-term outcomes of patients who underwent concomitant aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) surgery. We retrospectively reviewed 150 patients who underwent AVR-CABG at our institution between January 1997 and December 2006. We divided patients into aortic stenosis (AS), aortic regurgitation (AR), and mixed-type groups consisting of 98 (65.3%), 20 (13.3%) and 32 (21.3%) patients, respectively. The AS group had more female patients, a higher mean angina class, older mean patient age, increased history of previous myocardial infarction (MI), and smaller valve size compared to other groups. No significant differences were observed among groups in the operative mortality for five or ten-year survival rates. Significant early mortality risk factors included cross-clamp and cardiopulmonary bypass (CBP) time, number of blood transfusion units, chronic obstructive pulmonary disease (COPD), intra-aortic balloon pump (IABP), inotropic drugs, and pacemaker use. Significant late mortality risk factors included intensive care unit (ICU) stay, IABP, stroke, and dialysis. The aortic valve pathology type in patients undergoing concomitant AVR-CABG does not adversely affect survival.

Cardiac papillary fibroelastoma as a reason of transient ischemic attack for a young patient.

Cardiac papillary fibroelastoma is a rare primary cardiac tumor. It occurs mainly in the endothelium of cardiac valves. Although cardiac papillary fibroelastomas are benign tumors, they have potential life threatening complications such as sudden death, stroke, and myocardial infarction. A young man who presented two syncope attacks referred to our hospital for cardiac examination. A mass was found attached to the anterior mitral leaflet, detected by transthoracic echocardiography. We planned an urgent surgery for the patient. During operation, we found out the cauliflower shaped mass on the atrial side of the anterior mitral leaflet. We excised the tumor completely without damage to the mitral valve. We confirmed the diagnosis histopathologically. Intracardiac tumors must be excised urgently due to severe complications. It's so important to protect native valve leaflets during the excision of papillary fibroelastoma with low rates of recurrence.