Biochemical predictors of postoperative atrial fibrillation following cardiac surgery.

BACKGROUND: New-onset postoperative atrial fibrillation (POAF) is common after cardiac surgery. Early identification of its risk factors during the preoperative period would help in reducing the associated morbidity, mortality, and healthcare costs. AIM OF THE STUDY: This study aimed to identify the predictors of POAF following open cardiac surgery, with emphasis on biochemical parameters. METHODS: A total of 1191 patients with no preoperative atrial fibrillation (AF) and undergoing open cardiac surgery for any reason were included in this retrospective study. Data on clinical and biochemical parameters, the occurrence of new-onset AF, and its clinical course were retrieved from the hospital database. RESULTS: During the early postoperative period 330 patients (27.7%) developed atrial fibrillation, at median third postoperative day (range 1-6 days) and 217 (65.8%) responded to treatment. Multivariate analysis identified the following as the significant independent predictors of any POAF: EF < 60% (Odds ratio (OR), 2.6), valvular intervention (OR, 2.4), liver failure (OR, 2.4), diabetes (OR, 1.6), low hematocrit (OR, 2.1), low thrombocyte (OR, 5.6), low LDL (OR, 1.6), high direct bilirubin (OR, 2.0), low GFR (OR, 1.6), and high CRP (OR, 2.0). Following parameters emerged as significant independent predictors of persistent AF: EF < 60% (OR, 1.9), diabetes (OR, 2.1), COPD (OR, 1.8), previous cardiac surgery (OR, 3.1), valvular intervention (OR, 2.4), low hematocrit (OR, 1.9), low LDL (OR, 2.1), high HbA1c (OR, 2.0), and high CRP (OR, 2.7). CONCLUSIONS: Certain parameters assessed during preoperative physical and laboratory examinations have the potential to be used as markers of POAF.

The effect of treated apical periodontitis before heart valve surgery on C-reactive protein levels.

OBJECTIVE: Dental infections produce significant increases in systemic inflammatory responses manifested by cytokines and acute-phase reactants. This study evaluated the postoperative C-reactive protein (CRP) levels according to patients having teeth treated or not treated for apical periodontitis (AP) before heart valve surgery. MATERIALS AND METHODS: Preoperative, postoperative third- and fifth-day CRP levels, and the previous dental data of 91 patients were investigated. Whether the patients had been treated for AP and whether they used antibiotic prophylaxis for this treatment were determined by examining the previous data. The analysis of covariance (ANCOVA) was used for statistical analysis. RESULTS: There were no statistically significant differences in the preoperative CRP levels and the third-day CRP levels between all patients treated and those not treated for AP (p > .05). The mean fifth-day CRP levels of the patients with teeth treated for AP were significantly lower than those of the patients with teeth not treated for AP (p < .05). Antibiotic prophylaxis had a significant effect on the fifth-day CRP levels. CONCLUSION: The decrease in CRP levels after AP treatment may contribute to alleviating heart valve disease and maintaining cardiac health.

Neutrophil to lymphocyte ratio: a novel marker for predicting hospital mortality of patients with acute type A aortic dissection.

INTRODUCTION: The inflammatory process has been reported to be associated with aortic dissection (AD) from the development to the prognosis. The aim of the study was to investigate a relationship between the neutrophil to lymphocyte ratio (NLR) and in-hospital outcomes in patients with acute aortic dissection (AAD) who underwent surgical repair. METHODS: One hundred and eighty-four patients who were admitted with the diagnosis of type A AAD who underwent surgical repair at two large tertiary hospitals. According to their NLR, 91 patients had high NLR (>6.0) and 93 patients had low NLR (⩽6.0). RESULTS: The frequency of major bleeding, hospital-related infection, multi-organ dysfunction and mortality in hospital were higher in the high NLR group compared to the low NLR group. NLR, WBC count and operation duration were found to be independent predictors for in-hospital mortality. CONCLUSIONS: The novel inflammatory marker NLR may be used to predict worse outcomes and hospital mortality in patients with AAD treated by surgical repair.

Evaluation of Aortic Paravalvular Leak: A Special Reference for Anatomical Localization.

BACKGROUND AND AIM OF THE STUDY: Paravalvular leakage (PVL) remains an unavoidable complication of heart valve surgery and in its severe forms may lead to heart failure and hemolysis. The study aim was to evaluate the echocardiographic, clinical, surgical and laboratory characteristics of patients with aortic PVL. METHODS: A total of 77 aortic PVL patients underwent transthoracic and transesophageal echocardiography examinations. Clinical, echocardiographical and surgical findings were also recorded. RESULTS: Among the 77 patients, 21 (27.3%) had mild, 33 (42.8%) had moderate and 23 (29.9%) had severe aortic PVL. Seventeen patients (22.1%) had moderate-to-severe hemolysis and had a higher incidence of multiple PVL compared to those with no or mild hemolysis. Moderate- to-severe PVL was more frequent between the non-coronary and the left coronary sinus annuli, especially adjacent to the left main coronary artery ostium. Percutaneous closure was performed in five patients. Eleven patients underwent surgical repair, and the localizations of PVL were in accordance with echocardiographic findings. CONCLUSIONS: Aortic PVL occurs more frequently between the non-coronary sinus and the left coronary sinus annuli, which may be associated with multiple factors. Difficulties in seating the prosthesis due to the steep angulation of the commissure and annulus, the avoidance of deep sutures, and focal annular calcification may make this region prone to injury and leakage.

Histopathological and Immunohistochemical Evaluation of Pannus Tissue in Patients with Prosthetic Valve Dysfunction.

BACKGROUND: Prosthetic valve dysfunction due to pannus formation is a rare but serious complication. Currently, limited data are available concerning the pathogenesis and immunohistochemical properties of pannus. The study aim was to investigate the morphological, histopathological and immunohistochemical characteristics of pannus formation in patients with prosthetic valve dysfunction. METHODS: A total of 35 patients (10 males, 25 females; mean age 44 ± 16 years) who had undergone re-do valve surgery due to prosthetic valve obstruction was enrolled in the study. Immunohistochemical studies were aimed at evaluating the expression of alphasmooth muscle actin (α-SMA) and desmin in myofibroblasts and smooth muscle cells; epithelial membrane antigen (EMA) in epithelial cells; and CD34, Factor VIII and vascular endothelial growth factor (VEGF) in endothelial cells. Matrix metalloproteinases (MMPs) -2 and -9, and transforming growth factor-beta (TGF-ß) were used to demonstrate cytokine release from macrophages, leukocytes, fibroblasts and myofibroblasts. RESULTS: Pannus appeared as a tough and thick tissue hyperplasia which began from outside the suture ring in the periannular region and extended to the inflow and outflow surfaces of the prosthetic valves. Histopathological analysis showed the pannus tissue to consist of chronic inflammatory cells (lymphocytes, plasma cells, macrophages and foreign body giant cells), spindle cells such as myofibroblasts, capillary blood vessels and endothelial cells laying down the lumens. Calcification was present in the pannus tissue of 19 explanted prostheses. Immunohistochemical studies revealed positive α-SMA expression in all patients, whereas 60.5% of patients were positive for desmin, 50% for EMA, 42.1% for VEGF, 39.5% for TBF-ß, 42.1% for MMP-2, 86.8% for CD34, and 97.4% for Factor VIII. MMP-9 was negative in all patients. CONCLUSIONS: Pannus tissue appears to be formed as the result of a neointimal response in periannular regions of prosthetic valves that consist of periannular tissue migration, myofibroblast and extracellular matrix proliferation with vascular components. It is a chronic active process in which mediators such as TGF-ß, VEGF and MMP-2 play roles in both matrix formation and degradation.

An unusual mass of tricuspid valve in an adult patient: blood-filled cyst.

Blood-filled cysts (BFC) within the heart are common findings at postmortem examinations of fetuses and infants. However, such cysts are very rare entities in adolescents and adults. We report here an adult case of BFC attached to the posterior leaflet of the tricuspid valve, demonstrating the importance of multimodal diagnostic imaging combining both echocardiography and magnetic resonance imaging.

Intravenous iloprost for treatment of critical limb ischemia in patients unsuitable for revascularization.

INTRODUCTION: Whether medical therapy alone may reduce the amputation rates in patients with chronic limb ischemia and who are unsuitable for revascularization is a controversial topic. In this study, we aimed to investigate the effects of 1 week infusion of iloprost in the treatment of patients with chronic limb ischemia. MATERIALS AND METHODS: Twenty-seven consecutive patients were included in the study. There were 23 men (85.2%) and 4 women (14.8%) with a mean age of 68.93 ± 14.84 years. Patients were considered eligible if they were unsuitable for surgical and endovascular revascularization. Follow-up was made on 10th day and 6th month and included ankle brachial index and clinical assessment. RESULTS: Minor side effects occurred in four patients (16.0%), but the treatment was continued. In-hospital mortality occurred in one patient (4.0%). Another two patients died and four patients received amputation until follow-up (overall mortality 11.1%). There was significant increase in mean ankle-brachial index values between 1st day and 10th day (p < 0.001), between 1st day and 6th month (p < 0.001), and between 10th day and 6th month (p < 0.001). CONCLUSION: One-week treatment with iloprost may provide both long lasting symptomatic benefit and may improve hemodynamic parameters, which were shown to predict future amputation.

Levosimendan improves renal outcome in cardiac surgery: a randomized trial.

OBJECTIVE: The effect of levosimendan on renal function in patients with low ejection fraction undergoing mitral valve surgery was investigated. DESIGN: A prospective, double-blinded, randomized clinical trial. SETTING: Tertiary teaching and research hospital. PARTICIPANTS: Of a total of 147 patients, 128 patients completed the study. In the levosimendan group (n = 64), levosimendan was administered in addition to standard inotropic support; whereas, in the control group (n = 64), only standard inotropic support was given. INTERVENTIONS: In the levosimendan group, a loading dose of levosimendan (6 µg/kg) was administered after removal of the aortic cross-clamp, followed by an infusion (0.1 µg/kg/min) in addition to standard inotropic therapy for 24 hours. In the control group, only standard inotropic therapy was administered. Preoperative characteristics, serum creatinine (sCr) levels, and estimated glomerular filtration rate (eGFR) were determined preoperatively, on postoperative days 1, 3, and 10. Independent risk factors for renal replacement therapy (RRT) requirement were investigated with stepwise multivariate logistic regression analysis. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was the effect of levosimendan on postoperative renal clearance (sCr and eGFR). The secondary endpoint was the effect of levosimendan on clinical outcomes (length of intensive care unit and hospital stays, need for RRT). Preoperative characteristics and eGFR were similar between the groups (p>0.05). On postoperative days 1 and 3, sCr values were lower and eGFR values were higher in the levosimendan group in comparison with the control group (p = 0.0001, p = 0.009, respectively). Six patients (9.4%) in the levosimendan group and 10 patients (15.6%) in the control group required RRT therapy (p = 0.284). Independent risk factors for need of RRT include preoperative sCr value between 1.2 to 2.09 mg/dL and≥2.1 mg/dL (p< 0.05). CONCLUSIONS: Perioperative treatment with levosimendan in addition to standard inotropic therapy in patients with a low ejection fraction undergoing mitral valve surgery improved immediate postoperative renal function and reduced need for RRT.

The effect of iloprost on renal function in patients with critical limb ischemia.

BACKGROUND: Iloprost, which has efficacy in the microvascular space, is shown to have beneficial effects on the kidney, which has an extensive microvascular network. OBJECTIVE: We aimed to evaluate the effect of iloprost treatment on kidney functions in patients with critical limb ischemia. METHODS: Forty-eight patients with critical limb ischemia who were not suitable for revascularization and who were treated with iloprost were evaluated prospectively in our clinic between September 2010 and December 2012. The patients were divided into 2 groups as patients with chronic renal dysfunction (Group I) and patients with normal renal function (Group II). Urine albumin:creatinine ratio and glomerular filtration rate (GFR) calculated using serum creatinine and serum cystatin C (GFRcyc) were used to establish the presence of renal dysfunction. The decrease analgesic requirement, walking distance, reduction in ulcer diameter, the increase in ankle-brachial index, and changes in The Society of Vascular Surgery/International Society of Cardiovascular Surgery criteria were used in the evaluation of treatment response. RESULTS: Opioid analgesic requirement and decubitus pain disappeared after treatment in 58.3% (n = 28) of subjects. Walking distance increased in 66.6% (n = 32). Iloprost treatment significantly increased ankle-brachial index (P < 0.01). In Group I the levels of serum urea, creatinine, and cystatin C significantly decreased (P < 0.05), whereas GFRcyc and GFR calculated using the equation of the Chronic Kidney Disease Epidemiology Collaboration (ie, GFR expressed for specified race, sex, and serum creatinine in milligrams per deciliter) was increased significantly compared with pretreatment levels (P < 0.05). No significant change was observed in urine albumin:creatinine ratio (P > 0.05). CONCLUSIONS: The use of iloprost in critical limb ischemia can slow down the progress of early stage renal damage. GFRcyc and cystatin C, which are indicators of early stage chronic renal dysfunction, can be used for the evaluation of treatment response.

Thoracic aortobifemoral bypass in treatment of juxtarenal Leriche syndrome (midterm results).

BACKGROUND: The standard surgical treatment of infrarenal aortoiliac obstructive disease is abdominal aortobifemoral bypass (AABFB). However, alternative surgical procedures may be considered in cases of juxtarenal Leriche syndrome and previous aortofemoral graft obstruction. We present midterm results of 20 consecutive patients who underwent thoracic aortobifemoral bypass (TABFB) either as primary or secondary procedure. METHOD: Between 1999 and 2010, 20 patients who were diagnosed to have juxtarenal Leriche syndrome (n = 17) and failure of previous AABFB graft (n = 3) were enrolled. The patients were classified according to the Rutherford classification. Mean follow-up period was 60.9 ± 38.3 months. Mean preoperative ankle-brachial index on the left lower extremity was 0.18 and on the right lower extremity was 0.20. RESULTS: Seventeen patients with the diagnosis of juxtarenal Lercihe syndrome were primarily and three patients were secondarily (for treatment of failed previous AABFB graft) treated using TABFB procedure. The mean ankle-brachial index at last follow-up was 0.75 on the left lower extremity and 0.76 on the right. One-year patency rate was 100%, and 5-year patency rate was 94%. CONCLUSION: TABFB precludes the risk of renal artery embolization in cases of juxtarenal obstruction, without adding any risk of morbidity and mortality. Its long-term patency is similar or even superior to conventional surgical bypass techniques. We propose its use as an initial treatment in juxtarenal Leriche syndrome as well as a remedial procedure in cases with previous AABFB graft occlusion.

A new form of coronary subclavian steal syndrome: a saphenous vein graft-coronary-subclavian unidirectional steal syndrome.

Coronary subclavian steal syndrome refers to decreased or reversed internal mammary artery flow, which causes angina related to severe subclavian steno-occlusive disease in patients with in situ internal mammary-to-coronary artery graft. We present a 48-year-old man with cerebrovascular and peripheral artery disease and the first case in the literature of a saphenous vein graft-coronary-subclavian unidirectional steal syndrome.

The use of posterior pericardiotomy technique to prevent postoperative pericardial effusion in cardiac surgery.

AIM: The goal was to determine the effectiveness of the posterior pericardiotomy technique in preventing the development of early and late pericardial effusions (PEs) and to determine the role of anxiety level for the detection of late pericardial tamponade (PT). MATERIALS AND METHODS: We divided 100 patients randomly into 2 groups, the posterior pericardiotomy group (n = 50) and the control group (n = 50). All patients undergoing coronary artery bypass grafting surgery (CABG), valvular heart surgery, or combined valvular and CABG surgeries were included. The posterior pericardiotomy technique was performed in the first group of 50 patients. Evaluations completed preoperatively, postoperatively on day 1, before discharge, and on postoperative days 5 and 30 included electrocardiographic study, chest radiography, echocardiographic study, and evaluation of the patient's anxiety level. Postoperative causes of morbidity and durations of intensive care unit and hospital stays were recorded. RESULTS: The 2 groups were not significantly different with respect to demographic and operative data (P > .05). Echocardiography evaluations revealed no significant differences between the groups preoperatively; however, before discharge the control group had a significantly higher number of patients with moderate, large, and very large PEs compared with the pericardiotomy group (P < .01). There were 6 cases of late PT in the control group, whereas there were none in the pericardiotomy group (P < .05). Before discharge and on postoperative day 15, the patients in the pericardiotomy group showed significant improvement in anxiety levels (P = .03 and .004, respectively). No differences in postoperative complications were observed between the 2 groups. CONCLUSION: Pericardiotomy is a simple, safe, and effective method for reducing the incidence of PE and late PT after cardiac surgery. It also has the potential to provide a better quality of life.

Fatal Autonomic Dysfunction Due to Guillain-Barré Syndrome After Cardiac Surgery.

Guillain-Barré syndrome, a rare peripheral neuropathy, appears to occur more often in patients who have recently undergone surgery than in the general population. However, the pathophysiologic relationship between surgery and Guillain-Barré syndrome is elusive. Few cases of Guillain-Barré syndrome after cardiac surgery have been reported. Autonomic dysfunction, a serious complication of Guillain-Barré syndrome, has not been previously reported after cardiac surgery. We describe the case of a 71-year-old woman in whom the acute motor axonal neuropathic subtype of Guillain-Barré syndrome developed after mitral valve replacement. Despite plasmapheresis and intravenous immunoglobulin therapy, she died of complications from severe autonomic dysfunction 25 days postoperatively. Recognizing the potential cardiovascular involvement of Guillain-Barré syndrome is important, because patients who undergo cardiac surgery can be vulnerable to autonomic dysfunction in the early postoperative period.

A novel approach of tricuspid valve repair: mitralization of tricuspid valve.

OBJECTIVES: This study presents the mid-term results of a novel tricuspid valve (TV) repair strategy defined as 'mitralization of TV' (resection and plication of the posterior leaflet, ring implantation, optional leaflet procedures) applied for the correction of tricuspid regurgitation (TR). METHODS: Between 2017 and 2020, a total of 22 patients underwent concomitant TV repair using mitralization of the TV. Fourteen of the patients had functional TR (2 of them had severe tethering), 5 patients had prolapse and 3 patients had rheumatic involvement. RESULTS: There was no in-hospital mortality. Moderate or severe TR was not observed in any patient in echocardiographic evaluations before discharge. The mean follow-up duration was 30.9 + 6.2 months. Moderate-to-severe TR-free survival was 100% in the second year and 94.7% in the third year. CONCLUSIONS: Mitralization of the TV is a safe and effective treatment modality in terms of its mid-term results. This new technique provides an innovative perspective for the treatment of TR, especially in complex TV pathologies.

Comparative efficacy and life quality effects of surgical stripping, radiofrequency ablation, and cyanoacrylate embolization in patients undergoing treatment for great saphenous vein insufficiency.

OBJECTIVES: To compare traditional surgery with two minimally invasive endo-venous procedures in terms of their long-term effect on the quality of life in great saphenous vein insufficiency (GSV). METHOD: This prospective observational study included 217 patients that underwent surgical stripping (n = 62), radiofrequency ablation (n = 70), or cyanoacrylate embolization (n = 85) for the treatment of GSV insufficiency. Venous Clinical Severity Score (VCSS) assessments were made, 36-item Short-Form Health Survey (SF-36) questionnaire and Chronic Venous Insufficiency quality of life Questionnaire (CIVIQ-14) were administered, before and 1 year after the treatments. RESULTS: Surgical stripping group had significantly higher closure rates than the other groups (p < 0.05). At 12 months, decrease in VCSS scores was less pronounced in the cyanoacrylate embolization group when compared to the other two groups (p < 0.05). Improvement in CIVIQ-14 scores was better in the radiofrequency ablation group when compared to the cyanoacrylate embolization group (p < 0.05). Surgical stripping or radiofrequency ablation groups performed better on several domains of SF-36, when compared to the cyanoacrylate embolization group. CONCLUSIONS: Surgical stripping and radiofrequency ablation seem to provide a better quality of life results at one year in patients undergoing treatment for GSV insufficiency.

Analysis of Readmissions to The Intensive Care Unit After Coronary Artery Bypass Surgery: Ten Years' Experience.

OBJECTIVE: To evaluate the frequency, causes, and related predictive factors of intensive care unit (ICU) readmissions after coronary artery bypass grafting (CABG) surgery. METHODS: A total of 4112 consecutive patients who underwent on-pump CABG between January 2007 and January 2017 were retrospectively evaluated. The patients were divided into two groups as patients with and without ICU readmission. Demographic and perioperative characteristics were compared between the two groups. RESULTS: The ICU readmission rate was 3.5%. The most common reasons for ICU readmissions were respiratory (29%) and cardiac (23.4%) complications. The 90-day mortality risk was significantly higher in the readmitted patients than the non-readmitted patients (22.1% and 1.6%, respectively; P<0.001; OR=17.6; 95% CI=11.19-28.41). Severe left ventricular dysfunction, chronic obstructive pulmonary disease, end-stage renal disease, emergency CABG, EuroSCORE II > 5%, cross-clamp time > 35 minutes, postoperative respiratory complications, neurological complications, and cardiac complications showed a strong association with ICU readmissions. CONCLUSION: ICU readmission after CABG is associated with an increased mortality rate. Evaluation, not only of patients' comorbidities, but also of intraoperative conditions and postoperative complications, is important to identify patients at risk for ICU readmission.