Total aortic arch replacement without deep hypothermic circulatory arrest in type A aortic dissection: Left axillar artery for arterial cannulation.

Objective: Total aortic arch replacement (TAR) necessitates hypothermic circulatory arrest (CA). The frozen elephant trunk technique (FET) additionally requires commercial hybrid grafts. Herein we describe a novel modified FET technique without CA using standard grafts thanks to left axillary artery (LAxA) cannulation in patients with acute type A aortic dissection. Methods: LAxA anastomosis is made first using a homemade debranching graft, and cardiopulmonary bypass is initiated, followed by anastomoses of left common carotid and innominate arteries. The rest of the operation is performed with complete cerebral perfusion. Following replacement of ascending aorta/root, cardiac reperfusion is started using a root cannula which continues throughout the procedure. Distal arch anastomosis is performed clamp-on, allowing lower body perfusion via left subclavian artery. Lower body perfusion is interrupted for 5 to 8 minutes to deploy an endograft to complete a modified FET. Following cannulation of distal arch graft, perfusion of distal aorta is restarted, and all three grafts are incorporated to construct a neo-ascending aorta and arch. Results: Between December 2018 and May 2022, 38 patients underwent TAR without operative mortality. Hospital mortality was %15.7, and spinal cord ischemia and stroke were not encountered in surviving patients. The mean lower body CA time was 7.2 ± 2.8 minutes. Conclusions: TAR using standard endografts without CA is possible with LAxA cannulation. To perform a FET, only a short interruption of lower body circulation is sufficient to deploy an endograft, also improving hemostasis of distal anastomosis. Further studies are required with a higher number of patients to evaluate the efficiency of this novel technique.

Mid-Term Results of Left Carotid-Subclavian Bypass in Patients Undergoing Zone 2 TEVAR.

INTRODUCTION: The aim of this study was to present the mid-term results of patients who had undergone a carotid-subclavian bypass surgery after a thoracic endovascular aortic repair (TEVAR) stent-graft implantation with proximal landing at zone 2 of the aorta. METHODS: A total of 66 patients had undergone TEVAR and carotid-subclavian bypass between January 2015 and May 2020 at our clinic. Five of these patients were lost to follow-up, so 61 patients were included in this retrospective study. At follow-up visits, patency of the carotid-subclavian bypass grafts was evaluated with physical examination and radiological imaging. RESULTS: The mean follow-up time was 15.11±12.29 months (ranging from 1 to 56 months). There were 3 (4.91%) in-hospital deaths of patients admitted with bilateral lower limb and visceral malperfusion. There were also 2 (3.27%) deaths unrelated to the procedure. Carotid-subclavian graft occlusion occurred in 3 (4.91%) patients. The occlusion was detected with radiological imaging within a period of 12 to 24 months. The graft patency rate was 100% in the first 12 months. The mean graft patency time (survival) was 52.56±2.10 months. CONCLUSION: Periprocedural carotid-subclavian bypass surgery with synthetic grafts is a recommended procedure with high patency and acceptably low mortality and morbidity rates in TEVAR.

Sequential left internal mammary artery grafting in combination with the aortic no-touch technique.

Aim: This study aimed to investigate the short-term outcomes achieved with off-pump bypass combined with the aortic no-touch technique where sequential anastomoses between the left internal mammary artery (LIMA), left anterior descending (LAD) and diagonal artery were employed. Material and methods: A total of 583 patients (mean age 63, 80% male) who underwent off-pump bypass (LIMA-diagonal-LAD sequential) were enrolled in this retrospective analysis. Data regarding the frequency of in-hospital postoperative complications, intra-aortic balloon pump (IABP) and inotropic agent requirement, re-exploration for bleeding, and length of hospital stay were collected. Anastomosis patency was evaluated in 49 patients who underwent angiography. Results: 2.6% of the participants received inotropic agents and 0.5% required IABP. Frequency of acute renal failure, sternal wound infection, cerebrovascular event, respiratory failure, and hemodialysis was less than 1% in total. Among the 49 patients undergoing angiography at an average 41 ±17 months after bypass, the LIMA-LAD was patent in 98% and the LIMA-diagonal was patent in 84% of the subjects. Preoperative left ventricle ejection fraction (LVEF) and recent myocardial infarction (MI) prior to bypass were significantly correlated with postoperative IABP and inotropic agent requirement (r = 0.165, p < 0.01 for LVEF, p = 0.021 for recent MI). Conclusions: Off-pump bypass in combination with the aortic no-touch technique is associated with favorable postoperative outcomes including reduced postoperative stroke, renal dysfunction, IABP, and inotropic agent requirement compared to the results of previous randomized prospective studies published in the literature.

Short-term results of chimney stent revascularization of left subclavian artery and Zone 2 thoracic endovascular aortic repair for patients with aortic dissection or transection.

Background: In this study, we present the short-term results of revascularization of left subclavian artery with the chimney technique in patients with aortic dissection or transection who underwent Zone 2 thoracic endovascular aortic repair. Methods: A total of 11 patients (6 males, 5 females; mean age: 56.4±11.5 years; range, 38 to 76 years) who underwent Zone 2 thoracic endovascular aortic repair procedure and left subclavian artery revascularization with the chimney technique between April 2017 and January 2020 in our clinic were retrospectively analyzed. All patients were followed at one, three, six months and one year with computed tomography angiography. Results: The mean follow-up was 19.7±14.5 (range, 6.3 to 45.8) months. Endoleak occurred in one (9%) patient and gutter leak occurred in three (27%) patients. The mean endoleak-free (including gutter leak) time was 19.9±5.4 (95% confidence interval: 9.36-30.34) months. No mortality occurred in any of the patients. No occlusion occurred in the chimney grafts. Conclusion: The chimney revascularization technique is an alternative to other revascularization techniques of the left subclavian artery during thoracic endovascular aortic repair.

Endovascular solution in a complex post-dissectional thoracic aortic aneurysm case.

A 45-year-old male patient presented to our clinic with a post-dissectional thoracic aortic aneurysm with the retrograde filling of the false lumen. He previously underwent a Bentall operation and a proximal thoracic endovascular aortic repair. We carried out a bare metal stent implantation concomitant with endograft extension and stent-assisted balloon-induced intimal disruption and relamination procedure consecutively. Although true lumen expansion was achieved, the aneurysmatic dilation of the descending thoracic aorta was kept on expanding due to perfusion of the false lumen by the distal re-entries. Therefore, it was decided to perform a totally false lumen thrombosis by the candy-plug technique. In conclusion, despite being a fatal disease, endovascular treatment of post-dissectional thoracic aortic aneurysm post-dissectional thoracic aortic aneurysm is possible in anatomically suitable patients with a stepwise approach in experienced endovascular centers.

Cardiac Output Values and Correlation of Renal Injury with Neutrophil Gelatinase-Associated Lipocalin Levels in Off-Pump Coronary Artery Bypass Patients.

OBJECTIVE: To investigate the correlation between cardiac output values and renal neutrophil gelatinase-associated lipocalin (NGAL) levels as a biomarker of renal ischemia. METHODS: Forty patients, who underwent off-pump coronary artery bypass (OPCAB) surgery and in whom the positioning of the heart was fixed with simple suspension sutures without a mechanical stabilizer, were included in the study. Continuous cardiac output (CO) measurements were recorded using the arterial pressure waveform analysis method (FloTrac sensor system) in the perioperative period. CO was recorded every minute during non-anatomical cardiac positioning for left anterior descending artery (LAD), diagonal artery (D), circumflex artery (Cx), and right coronary artery (RCA) bypasses. Serum NGAL samples were analyzed in the preoperative, perioperative, and postoperative periods. RESULTS: The CO values measured at various non-anatomical cardiac positions during distal anastomosis for LAD, D, Cx, and RCA were significantly lower than pre- and postoperative values measured with the heart in normal anatomical position (3.45±0.78, 2.9±0.71, 3.11±0.56, 3.19±0.81, 5.03±1.4, and 4.85±0.78, respectively, P=0.008). There was no significant difference between CO values measured at various non-anatomical cardiac positions during distal anastomosis. Although there was no significant correlation between NGAL levels and age, duration of surgery, preoperative CO, D-CO, RCA-CO, and postoperative CO measurements, there was a significant correlation between NGAL levels and LAD-CO (P=0.044) and Cx-CO (P=0.018) at the postoperative 12th hour. CONCLUSION: Full revascularization may be achieved by employing the OPCAB technique while using simple suspension sutures without a mechanical stabilizer and by providing safe CO levels and low risk of renal ischemia.

Cardiac output values and correlation of renal injury with neutrophil gelatinase-associated lipocalin levels in off-pump coronary artery bypass patients

Abstract Objective: To investigate the correlation between cardiac output values and renal neutrophil gelatinase-associated lipocalin (NGAL) levels as a biomarker of renal ischemia. Methods: Forty patients, who underwent off-pump coronary artery bypass (OPCAB) surgery and in whom the positioning of the heart was fixed with simple suspension sutures without a mechanical stabilizer, were included in the study. Continuous cardiac output (CO) measurements were recorded using the arterial pressure waveform analysis method (FloTrac sensor system) in the perioperative period. CO was recorded every minute during non-anatomical cardiac positioning for left anterior descending artery (LAD), diagonal artery (D), circumflex artery (Cx), and right coronary artery (RCA) bypasses. Serum NGAL samples were analyzed in the preoperative, perioperative, and postoperative periods. Results: The CO values measured at various non-anatomical cardiac positions during distal anastomosis for LAD, D, Cx, and RCA were significantly lower than pre- and postoperative values measured with the heart in normal anatomical position (3.45±0.78, 2.9±0.71, 3.11±0.56, 3.19±0.81, 5.03±1.4, and 4.85±0.78, respectively, P=0.008). There was no significant difference between CO values measured at various non-anatomical cardiac positions during distal anastomosis. Although there was no significant correlation between NGAL levels and age, duration of surgery, preoperative CO, D-CO, RCA-CO, and postoperative CO measurements, there was a significant correlation between NGAL levels and LAD-CO (P=0.044) and Cx-CO (P=0.018) at the postoperative 12th hour. Conclusion: Full revascularization may be achieved by employing the OPCAB technique while using simple suspension sutures without a mechanical stabilizer and by providing safe CO levels and low risk of renal ischemia.

Comparison of heat induced damage at the saphenofemoral junction after ablation with 1,470 nm laser or radiofrequency.

BACKGROUND: The aim of this study was to evaluate the heat induced damage at the saphenofemoral junction level according to histopathological changes after radiofrequency or 1,470 nm radial tip laser ablation. PATIENTS AND METHODS: Varicose vein segments of 6-10 mm in diameter were exposed to radiofrequency (Closure Fast catheter, 7 cm heat segment, one cycle, 15 seconds, 10 Watt, 120 °C) or laser ablation (1,470 nm radial tip, continuous wave, vein diameter: 6 cm/8 cm/10 cm-power: 10 Watt-pullback speed: 2.2 mm/s, 1.7 mm/s, 1.3 mm/s-LEED: 45J/cm, 60J/cm, 75J/cm-EFE 25J/cm2, respectively). Approximate 2 cm segments of the vein were left untreated, then histopathological examinations of the untouched segments (5 slices: level 1 - furthest segment, level 2 - nearest segment) for heat induced damage were performed. A total damage scoring system was established, including the presence of endothelial swelling, intimal thickening, cellular vacuolisation in the muscle layer, oedema in the tunica media, and extent of necrosis. RESULTS: At level 1, the furthest segment of the specimen, there was no significant difference between the laser and control group, while the total damage score of the radiofrequency group was significantly higher than the control group (p < 0.01). Radiofrequency group had higher total damage score compared to the laser group at level 1 (p < 0.01), 2 (p < 0.01), and 5 (p < 0.01); while no significant difference was observed at level 3 (p = 0.46) and 4 (p = 0.13). CONCLUSIONS: Significant heat induced damage may be seen even if the 2 cm segment of the vessel is left unablated. Radiofrequency ablation seems to cause more histological damage than laser ablation in this ex vivo study. Further in vivo studies are necessary, in order to validate these findings.

The relationship between HbA1c & atrial fibrillation after off-pump coronary artery bypass surgery in diabetic patients.

OBJECTIVE: Diabetes mellitus is recognized as a risk factor for mortality and morbidity after coronary bypass grafting. We aimed to determine the association between preoperative hemoglobin HbA1c and AF after isolated off-pump coronary bypass grafting (OPCAB). METHODS: The seventy-two diabetic patients undergoing isolated off-pump coronary bypass grafting were retrospectively analyzed for AF. They were divided into; Low (4.8-5.4%), Medium (5.5-8%) and High (8.1-11.5%) groups. The three groups were compared with respect to demographic, echocardiographic, intraoperative and postoperative clinical characteristics correlation. RESULTS: Three patients died during postoperative period. AF occurred in 12 patients (16.6%) after surgery. The incidence of postoperative AF was 15.3% in the lower, 4.4% middle and 57.1% upper group. There was statistically significant correlation between preoperative HbA1C and preoperative stroke, preoperative MI history, Left atrial (LA) size, preoperative levosimendan, preoperative clopidogrel, postoperative AF, postoperative dopamine and dobutamine use, IABP, duration of extubation time, 24-hour chest tube drainage, duration of ICU and hospital mortality. Univariate logistic regression analysis showed significant correlation between postoperative AF and variables like preoperative HbA1c levels, LVEF<30%, history of preoperative MI, preoperative use of levosimendan, preoperative use of clopidogrel, postoperative dopamine, dobutamine adrenaline use, left atrium size, 24-hour chest tube drainage and length of stay in the intensive care unit. CONCLUSION: Preoperative HbA1c levels could predict the occurrence of postoperative AF in diabetic patients and may entail to administer protective strategies.

Left main coronary disease: improved early outcomes after off-pump coronary artery bypass grafting in high-risk patients.

BACKGROUND: Left main coronary artery (LMCA) stenosis is a risk factor in coronary artery bypass grafting (CABG). Although improved outcomes of off-pump CABG have been well documented, LMCA stenosis is often perceived as a contraindicationfor off-pump CABG. In this study, we compared on-pump and off-pump techniques in high-risk patients with LMCA disease. AIM: Documentation of safety and feasibility of off-pump CABG in patients with LMCA disease. METHODS: One hundred ninty nine patients with LMCA disease and a EuroScore ≥ 5 were operated upon between 2007 and 2010. One hundred patients (Group I) were operated upon using off-pump techniques, while 99 (Group II) were operated upon using conventional on-pump techniques. Perioperative variables and outcomes at first six months were compared. RESULTS: Despite higher mean age and EuroScore (70.9 ± 4.8 vs. 65.6 ± 7.9, p < 0.001, and 6.09 ± 0.8 vs. 5.31 ± 0.68,p < 0.001, respectively), and lower ejection fraction (41.4 ± 7.3 vs. 49.0 ± 6.2, p < 0.001), hospital mortality (1% vs. 6.1%,p = 0.065), postoperative inotropic support (9% vs. 48.4%, p < 0.001), blood loss (680.6 ± 265.0 vs. 847.2 ± 382, p < 0.001) and transfusions of blood (0.57 ± 0.79 U vs. 1.49 ± 0.82 U, p < 0.001), and hospital stay (6.57 ± 2.04 vs. 7.68 ± 3.44,p = 0.006) were lower in Group I. In both groups, mean number of distal anastomoses and completeness of revascularisation were similar. CONCLUSIONS: Using the off-pump technique is safe and improves postoperative early outcomes in high-risk patients with LMCA disease.

Double-edged sword in the heart: trapped deep venous thrombus in a patent foramen ovale.

Trapped thrombus in a patent foramen ovale is a rare condition. Echocardiography is the main tool for diagnosis and for determination of the treatment to choose. There are a number of treatment options for trapped deep venous thrombus in a patent foramen ovale, including surgical thrombectomy, thrombolytics, and anticoagulant therapy. All patients should be evaluated individually, because the systemic and pulmonary thromboembolism risk of all treatment options is like a 'double-edged sword'. Here, we report a case of a patient with trapped thrombus in the patent foramen ovale detected by echocardiography, and successfully treated with surgical thrombectomy under extracorporeal circulation.

The diagnosis and clinical importance of tumour neovascularisation from coronary artery to right atrial myxoma.

Myxomas are the commonest cardiac tumours and are usually localised in the atria. Neovascularisation in cardiac myxomas has been shown in previous case reports. However, the clinical importance of neovascularisation in cardiac myxomas is not well understood. In our case report, we present a right atrial myxoma in a 46 year-old woman admitted to our hospital with exertional angina and dyspnea. Coronary angiography revealed the presence of tumour neovascularisation from the right coronary artery, with no evidence of coronary artery stenosis. We thus speculate that neovascularisation of myxoma may cause typical anginal symptoms as a result of coronary steal phenomenon. Coronary angiography might help in the evaluation of the neovascularisation process and also in indicating surgery.

Primary valvular lipomatous hamartoma: a case report and a collective review of the literature.

Cardiac valvular tumors are very infrequent lesions constituting about 10% of the primary cardiac neoplasms. Among the valvular tumors, lipomatous hamartoma represents a very rare and distinct pathological entity. Retrieval of the literature reveals only eight reported cases, and there is lack of information regarding their clinical features. Herein, we describe a patient with a mass on the tricuspid valve detected incidentally and diagnosed to be a "lipomatous hamartoma." To obtain a better understanding of the nature of these unusual lesions, we reviewed the literature and presented their clinicoanatomical characteristics together with diagnostic and therapeutic approaches.

MDCT angiography of isolated right subclavian artery.

Isolation of a subclavian artery is an uncommon congenital anomaly of the aortic arch in which one subclavian artery loses its connection with the aorta and originates from the homolateral pulmonary artery by way of a ductus arteriosus. Isolation of the left subclavian artery in patients with a right aortic arch is well known. However, isolated right subclavian artery with a left-sided aortic arch is an extremely rare condition. In this report, we present multidetector computed tomographic (MDCT) angiography findings of an isolated right subclavian artery associated with a common carotid trunk and an anomalous origin and proximal interruption of the left pulmonary artery.

Biatrial compression caused by intrapericardial hematoma secondary to ruptured type I acute aortic dissection following aortic valve replacement.

Ruptured aortic dissection after aortic valve replacement (AVR) is uncommon and rarely diagnosed premortem. We report a patient with a ruptured type I aortic dissection and biatrial tamponade 2 months after AVR caused by loculated intrapericardial hematoma. The diagnosis was made by transthoracic echocardiography and confirmed at operation.

Effects of resveratrol on vascular tone and endothelial function of human saphenous vein and internal mammary artery.

BACKGROUND: The polyphenolic compound resveratrol presented in red wine has potent cardiovascular effect in animal. Here, we investigated the ability of resveratrol to relax human coronary bypass grafts, saphenous vein and internal mammary artery and also its effect on their endothelial reactivity. METHODS: Vascular rings were obtained from 38 male patients undergoing coronary artery bypass operation. The relaxant effects of resveratrol (10-70 microM) and acetylcholine (10(-8)-10(-4) M) were examined on precontracted saphenous vein and internal mammary artery rings. RESULTS: Resveratrol, at concentration of 70 microM caused relaxations of 34.2+/-5.7% in saphenous vein and 35.2+/-5.4% in internal mammary artery. Endothelium removal and l-NOARG (nitric oxide synthase inhibitor, 10(-4) M) pretreatment almost completely inhibited the relaxation to resveratrol in internal mammary artery but partially in saphenous vein rings. Indomethacin (cyclooxygenase inhibitor, 10(-5) M) slightly, but not significantly enhanced the relaxation to resveratrol in both vessels. The endothelium-dependent relaxations to acetylcholine were significantly improved in the presence of resveratrol of 20 microM in both grafts (E(max): 33.8+/-3.7% versus 46.8+/-4% in saphenous vein n=9; p<0.05; 54. 4+/-5.3% versus 69.3+/-5.4% in internal mammary artery, n=8, p<0.05). The relaxations to acetylcholine were fully eliminated by combination of resveratrol with l-NOARG (10(-4) M) in both vessels. CONCLUSIONS: Resveratrol produced mainly endothelium-dependent and nitric oxide-mediated vasodilation in human internal mammary artery but partially in saphenous vein rings and improved their endothelial reactivity. This may have a therapeutic potential in cardiovascular diseases.