Surgical Treatment of Vertebral Artery Stenosis: An Overlooked Surgery with Low Morbidity.

BACKGROUND: Vertebral artery (VA) stenosis as a cause of ischemic events and its surgical treatment is an overlooked subject. After reporting our initial results, the results of VA stenosis operations and the follow-up studies are analyzed. MATERIAL AND METHODS: This retrospective, single-center study includes 43 symptomatic proximal VA stenosis patients between September 2012 and March 2019. The demographics and clinical data were obtained from the hospital records. Doppler ultrasonography and computed tomography angiography were used to establish the diagnosis and for follow-up. The surgical procedures were as follows: VA transposition in 30 (69.8%), VA bypass 8 (18.6%), saphenous vein interposition in VA in 4 (9.3%), and decompression of kinking in 1 (2.3%) patient. Eleven patients (25.5%) had concomitant carotid surgery. The Kaplan-Meier method was used to calculate the survival and patency rates. RESULTS: Most common symptoms were vertigo and loss of balance in 38 (88.4%) and 14 (32.6%) patients, respectively. Twenty-five patients were males (58.1%), and the average age was 64.6 ± 9.8 (50-90) years. The 30-day death, 30-day stroke, and 30-day death/stroke rates were 2.3%, 4.7%, and 7%, respectively. Ten patients (23.3%) had morbidities which were related to the intervention. Horner syndrome was found in 5 (11.6%) patients, and facial nerve injury was found in one (2.3%) patient. Three (7.1%) patients died during the follow-up period, and overall survival of the patients at 3 years was 91.4% ± 5.8%. Two (4.7%) patients had cerebrovascular events (CVEs) occurred during the follow-up. One- and three-year CVE-free survivals were 97.1% ± 2.9% and 90.1% ± 7.2%, respectively. Two patients (5.4%) had restenosis. One- and three-year patency of VA after procedure was 89.1% ± 7.4%. Thirty-seven (86%) patients had complete recovery of symptoms after surgery; 5 patients (11.6%) kept their preoperative symptoms in different levels. CONCLUSIONS: Vertebral artery surgery can be performed with acceptable mortality and morbidity rates. Restenosis-free, CVE-free, and overall survival rates are satisfactory.

Autologous Saphenous Vein Panel Graft for Vascular Reconstruction.

BACKGROUND: This study aims to present early and midterm results of vascular reconstruction with saphenous vein panel graft. METHODS: Between August 2014 and August 2017, 11 saphenous vein panel grafts were used for vascular reconstruction in 10 patients. Patient data including age, gender, etiology of the vascular pathology, concomitant injury, site of injury, surgical procedure, additional surgical procedure, and hemodynamic status were retrospectively collected and analyzed. The Kaplan-Meier method was used to calculate the reintervention and patency rates. RESULTS: Mean duration of follow-up was 16.5 ± 13.2 months (ranged, 2-39 months). The freedom from reintervention for any reason was 82% at 1 and 2 years. There was no evidence of arterial claudication or venous insufficiency in all patients. The primary patency rates were 82% at 1 and 2 years. There was no mortality, deep venous thrombosis, pulmonary embolism, graft thrombosis, anastomotic stenosis, diameter discrepancy, and aneurysm formation during late follow-up. CONCLUSIONS: The autologous saphenous panel vein graft enables the surgeon to prepare suitable conduits easily with an appropriate diameter and length for vascular reconstruction. Although long-term results are unknown, this technique provides high patency rates in midterm follow-up, resistance to infection, and low reintervention rates. In conclusion, autologous saphenous vein panel grafts may well be preferred in various vascular disorders that require surgical reconstruction.

Prolonged mechanical ventilation after CABG: risk factor analysis.

OBJECTIVE: Prolonged ventilation (PV) after coronary artery bypass graft (CABG) surgery is a common postoperative complication. Preoperative and operative parameters were evaluated in order to identify the patients at risk for prolonged ventilation postoperatively in coronary artery bypass graft (CABG) patients. DESIGN: Retrospective. SETTING: Research and training hospital, single institution. PARTICIPANTS: The authors analyzed the prospectively collected data of 830 on- and off-pump coronary bypass patients. INTERVENTIONS: The relationships of PV (>24 hours) with preoperative and operative parameters were evaluated with logistic regression analysis. MEASUREMENTS AND MAIN RESULTS: Forty-six patients (5.6%) required PV postoperatively. Hospital mortality was significantly higher in this group (45.7% v 4.0%; p = 0.0001). Univariate analysis showed that these patients were older (65.6±9.3 v 60.4±9.9; p = 0.001), had higher incidences of cerebrovascular disease (21.7% v 10.5%; p = 0.032), advanced ASA (58.7% v 41.8%; p = 0.026) and NYHA classes (32.6% v 12.2%; p = 0.001), and chronic renal dysfunction (20.0% v 4.0%; p = 0.0001). Concomitant procedures were more commonly performed in these patients (30.4% v 7.8%; p = 0.0001), and total durations of perfusion were longer (147.2±69.1 v 95.7±33.9 minutes; p = 0.0001). In regression analysis, advanced NYHA class (odds ratio = 8.2; 95% CI = 1.5-43.5; p = 0.015), chronic renal dysfunction (odds ratio = 7.7; 95% CI = 1.3-47.6; p = 0.027), and longer perfusion durations (p = 0.012) were found to be independently associated with delayed weaning from the ventilator. Every 1-minute increase over 82.5 minutes of cardiopulmonary bypass increased risk of delayed extubation by 3.5% (95% CI = 0.8%-6.4%). CONCLUSIONS: Postoperative prolonged ventilation is associated with advanced NYHA class, chronic renal dysfunction and longer perfusion times in CABG patients.

Use of a lower cut-off value for HbA1c to predict postoperative renal complication risk in patients undergoing coronary artery bypass grafting.

OBJECTIVE: There is an increasing interest in reexamining the relationship between glucose levels and postoperative complications. Threshold levels of HbA1c below those currently recommended may be additional indicators of risk for renal and cardiovascular dysfunction. In this study, the authors analyzed the perioperative outcomes of coronary artery bypass graft (CABG) operations to evaluate the association of HbA1c levels and renal complications. DESIGN: Retrospective. SETTING: Research and training hospital, single institution. PARTICIPANTS: The prospectively collected data of 510 coronary bypass patients with documented HbA1c levels were analyzed. INTERVENTIONS: The relationship of HbA1c with postoperative renal morbidity was evaluated with logistic regression analysis with lower threshold value (5.9%) for elevated levels. MEASUREMENTS AND MAIN RESULTS: Two hundred ninety-three patients (57.5%) had elevated HbA1c values. Patients with high HbA1c levels (>5.9%) had higher incidences of atherosclerotic vascular diseases. The incidence of acute kidney injury was higher in the high HbA1c group (11.9% v 1.8%; p = 0.0001). The high HbA1c group had higher incidence of renal morbidity (odds ratio = 4.608), and every 1% increase over 5.9% increased risk of renal complications by 23.6%. The other factors associated with renal morbidity were known history of diabetes, chronic renal disease, and performance of any concomitant procedure. CONCLUSIONS: The elevated levels of HbA1c are associated with increased renal complications and the cut-off values of HbA1c could be lowered to the upper range of normal limits.

Innominate artery as an alternative site for proximal anastomoses in patients with a severely calcified aorta.

BACKGROUND: Atheromatous plaques of the ascending aorta are one of the most important risk factors for postoperative mortality and morbidity in coronary artery bypass grafting (CABG). We have retrospectively analyzed the results of proximal anastomoses constructed on the innominate artery in patients with calcific atheromatous plaques (CAP) in their ascending aorta detected intraoperatively. PATIENTS AND METHODS: This study is a retrospective review of 16 consecutive patients who underwent CABG operations and had CAP on their ascending aorta between November 2006 and June 2009. The atheromatous lesions were detected intraoperatively and the operation plan was changed to off-pump surgery. All the proximal anastomoses were made on the innominate artery, left internal thoracic artery (LITA) or the other saphenous vein grafts (SVG). Thirteen patients were male and three were female with a mean age of 63.7 ± 5.3 (ranged, 53-71) years. RESULTS: A total of 56 distal anastomoses (3.5 per patient) and 25 proximal anastomoses on the innominate artery were performed. Of the 16 patients, seven (43.7%) had received a sequential SVG; two (12.5%) patients, sequential LITA graft; and one (6.25%) patient sequential SVG and LITA graft. One of the proximal anastomoses was performed on the SVG in four patients (25%) and on the LITA graft in one patient (6.2%). One patient (6.2%) died due to cerebrovascular morbidity. No other complications were observed. CONCLUSIONS: The innominate artery is an alternative site for proximal anastomoses in patients with calcific atheromatous aorta.

Innominate Artery Cannulation for Proximal Aortic Surgery.

INTRODUCTION: The aim of this study was to evaluate the efficacy and safety of innominate artery cannulation strategy with side-graft technique in proximal aortic pathologies. METHODS: A total of 70 patients underwent innominate artery cannulation with a side graft for surgery on the proximal aorta from 2012 to 2020. There were 46 men and 24 women with an average age of 56±13 years. The indications for surgery were type A aortic dissection in 17 patients (24.3%), aortic aneurysm in 52 patients (74.3%), and ascending aorta pseudoaneurysm in one patient (1.4%). The innominate artery was free of disease in all patients. Hypothermic circulatory arrest with antegrade cerebral perfusion was utilized in 60 patients (85.7%). Three patients had previous sternotomy (4.2%). The most common surgical procedure was ascending aorta with hemiarch replacement in 34 patients (48.5%). RESULTS: The mean cardiac ischemia and cardiopulmonary bypass times were 116+46 minutes and 164+56 minutes, respectively. Mean antegrade cerebral perfusion time was 27+14 minutes. The patients were cooled between 22°C and 30°C during surgery. Thirty-day mortality rate was 7.1% (five patients). One patient (1.4%) had stroke, one patient (1.4%) had temporary neurologic deficit, and eight patients (11.4%) had confusion and agitation that resolved completely in all cases. There was no local complication or arterial injury. CONCLUSION: Cannulation of the innominate artery with side graft is safe and effective for both cardiopulmonary bypass and antegrade cerebral perfusion. This technique provides satisfactory neurologic outcomes for proximal aortic surgery.

Diagnostic criteria for Buerger's disease: International Consensus of VAS - European Independent Foundation in Angiology/Vascular Medicine.

Buerger's disease (BD) remains a debilitating condition and early diagnosis is paramount for its effective management. Despite many published diagnostic criteria for BD, selective criteria have been utilized in different vascular centers to manage patients with BD worldwide. A recent international Delphi Consensus Study on the diagnostic criteria of BD showed that none of these published diagnostic criteria have been universally accepted as a gold standard. Apart from the presence of smoking, these published diagnostic criteria have distinct differences between them, rendering the direct comparison of patient outcomes difficult. Hence, the expert committees from the Working Group of the VAS-European Independent Foundation in Angiology/Vascular Medicine critically reviewed the findings from the Delphi study and provided practical recommendations on the diagnostic criteria for BD, facilitating its universal use. We recommend that the 'definitive' diagnosis of BD must require the presence of three features (history of smoking, typical angiographic features and typical histopathological features) and the use of a combination of major and minor criteria for the 'suspected' diagnosis of BD. The major criterion is the history of active tobacco smoking. The five minor criteria are disease onset at age less than 45 years, ischemic involvement of the lower limbs, ischemic involvement of one or both of the upper limbs, thrombophlebitis migrans and red-blue shade of purple discoloration on edematous toes or fingers. We recommend that a 'suspected' diagnosis of BD is confirmed in the presence of a major criterion plus four or more minor criteria. In the absence of the major criterion or in cases of fewer than four minor criteria, imaging and laboratory data could facilitate the diagnosis. Validation studies on the use of these major and minor criteria are underway.

Repair of pulmonary artery aneurysms.

BACKGROUND AND AIM OF THE STUDY: We have presented the results of pulmonary arterial aneurysm repairs performed over eight years. METHODS: From 2002 to December 2010, we performed nine operations for pulmonary artery aneurysms in our department. The mean age of the patients was 37.8 ± 17.1 years and four were females. Five patients had pulmonic valve stenosis, three patients had concomitant pathologies on the aortic or mitral valves, and two had isolated pulmonary arterial aneurysm. Aneurysm repairs were performed by plication in eight patients and with Dacron patch repair in one patient. RESULTS: There were no postoperative deaths. Three patients required inotropic support postoperatively. One patient had pulmonary morbidity. The results of the pathology revealed intimal hyalinization, edema, and elastic fiber degeneration in the media, fibrosis in the adventitia, and increased vascularity. All patients were in New York Heart Association Class I or II except for one patient who had a prolonged intensive care stay. The mean duration of follow-up was 48.6 ± 33.2 months (range, 2 to 107) adding up to a total of 36.4 patient/years. The mean diameter of the pulmonary artery in the recent imaging was 3.6 ± 0.4 cm. CONCLUSION: Pulmonary artery aneurysms are rare entities which are usually associated with other congenital defects. While surgery is the preferred treatment for symptomatic aneurysms, controversy exists as to the indications for repair in asymptomatic patients.

Reduction of the sinotubular junction in patients undergoing ascending aortic replacement with coexisting aortic insufficiency.

BACKGROUND AND AIM OF THE STUDY: Dilatation of the STJ may cause consequent aortic insufficiency (AI) in patients with normal aortic valve, in patients with ascending aortic aneurysm. In this study, we analyzed the results of ascending aorta replacement with STJ diameter reduction to correct consequent AI in patients with ascending aortic aneurysm. METHODS: Forty-five consecutive patients who had ascending aortic aneurysm underwent replacement of ascending aorta with reduction of the STJ diameter to correct AI. Mean age of the patients was 61.3 ± 5.2. Twenty-six (57.8%) were female. Six patients had arch aneurysm. Postoperative echocardiographic studies were performed at discharge and annually thereafter. The mean duration of follow-up was 4.6 ± 2.9 years. RESULTS: Hospital mortality rate was 4.9% (n = 2). Three patients died during follow-up. Three patients had late recurrence of AI that was caused by aortic root dilatation. One of these patients required aortic valve replacement because of severe aortic insufficiency. The five-year survival and survival free from aortic insufficiency were 91.4%± 5.0% and 91.2%± 5.1%, respectively. CONCLUSIONS: Reduction of the diameter of STJ can be used to treat AI in patients with ascending aortic aneurysm with nearly normal aortic cusps. Midterm results of this procedure are encouraging.

National guidelines on the management of venous thromboembolism: Joint guideline of the Turkish Society of Cardiovascular Surgery, National Society of Vascular and Endovascular Surgery, and Phlebology Society.

These evidence-based guidelines from the Turkish Society of Cardiovascular Surgery, National Society of Vascular and Endovascular Surgery, and Phlebology Society intend to support clinicians in best decisions regarding the treatment of venous thromboembolism (VTE). The Editor was selected by the three national societies and was tasked with the recruitment of the recognized panel. All financial support was solely derived from the sponsoring societies without the direct involvement of industry or other external stakeholders. The panel prioritized clinical questions and outcomes according to their importance for clinicians in terms of VTE. The panel agreed on 42 recommendations under 15 headings for the diagnosis, initial management, secondary prevention of VTE, and treatment of recurrent VTE events. Important recommendations included the use of ultrasonography, preference for home treatment over hospital treatment for uncomplicated VTE, preference for direct oral anticoagulants (DOACs) over vitamin K antagonists for primary treatment of cancer and non-cancer-related VTE, extended or indefinite anticoagulation with DOACs in selected high-risk patients. Early catheter-directed thrombectomy was recommended in only young symptomatic patients with a diagnosis of fresh iliofemoral deep vein thrombosis.

Cusp shaving for concomitant mild to moderate rheumatic aortic insufficiency.

BACKGROUND: The aim of this study was to assess the early and mid-term results of patients who underwent cardiac operations due to cardiac pathologies other than aortic valve (AV) disease, but also had mild-to-moderate aortic valve insufficiency that was repaired during the same session. METHODS: A total of 43 patients who underwent AV repair for mild-to-moderate aortic insufficiency between January 2003 and February 2009, in addition to the procedure performed for their main pathology necessitating the surgical intervention, were included in the present study. Cardiac function was evaluated, before and after the operation. RESULTS: Hospital mortality rate was 4.6% (two patients). After the operations, significant improvements were observed in aortic insufficiency (0.57 +/- 0.50 vs. 2.86 +/- 0.48, p = 0.001), New York Heart Association class (1.08 +/- 0.28 vs. 3.03 +/- 0.44, p = 0.001), and left atrial diameter (47.37 +/- 9.28 vs. 42.35 +/- 7.02; p = 0.001). However, left ventricular end diastolic and end-systolic diameters remained unchanged. Two patients were re-operated for AV disease during the follow-up period; thus, at five years, the rate of freedom from re-operation due to AV pathology was 90.7 +/- 6.3%. CONCLUSIONS: Cusp shaving is a feasible option that can be performed with low risk for concomitant aortic insufficiency.

Left ventricular aneurysm using the Dor technique: mid-term results.

OBJECTIVE: We have retrospectively analyzed the early and the mid-term results of the operations for modified endoventricular circular patch plasty for left ventricular aneurysm (LVA) repair in our clinic. PATIENTS AND METHODS: Sixty-seven cases with anterior LVA were included in the study. Mean age of the patients were 64.8 +/- 8.9 (ranged from 51 to 74) years. Fifty-three patients were male and 14 female (M:F = 3.8). Preoperative left ventricular ejection fraction (LVEF) was 30.8% +/- 4.5%, LV end-diastolic diameter (LVEDD) 6.0 +/- 1.9 cm, and end-systolic diameter (LVESD) was 4.6 +/- 0.8 cm in average. Coronary revascularization was performed in 61 patients and mitral ring annuloplasty in five patients. RESULTS: Thirty-day mortality was 5.9%. The surviving 63 patients were followed up for 4.3 +/- 2.3 years on average (ranged from 0.2 to 8.5 years), adding up to 267.8 patient/years. In the immediate postoperative and long-term follow-up, there was a significant improvement in LVEF, LVESD, LVEDD, and mitral valvular function. Four patients died in the follow-up with only a single patient due to cardiac causes. The five years survival was 87.7% +/- 4.1% and the freedom from cardiac death was 98.2% +/- 1.7%. CONCLUSION: LVA repair with Dor procedure can be performed with low mortality. With appropriate repair of LVA and coronary revascularization, patients may have benefit both for survival and also for clinical status.

Radiofrequency ablation for atrial fibrillation in rheumatic valvular disease.

BACKGROUND: We have reviewed the results of radiofrequency ablation (RFA) in patients with rheumatic valve disease. METHODS: Sixty-seven patients underwent operation for rheumatic valvular disease and RFA concomitantly with the planned procedure. Twenty-two (32.8%) were male and 45 (67.2%) female. The mean duration of atrial fibrillation (AF) was 47.4+/-30.4 months (12-192). Logistic regression test was used to perform a risk factor analysis. RESULTS: Two patients died postoperatively (3.0%) and 3 died in the follow-up period (4.5%). One patient (1.5%) required permanent pacemaker. During the hospitalisation, 24 patients (35.8%) had AF but 6 of them returned to the normal sinus rhythm by the time of discharge. Forty-nine patients (73.1%) were discharged with normal sinus rhythm. The mean duration of follow-up was 15.1+/-15.2 months (0-59). Six patients (9.0%) had recurrent AF during the follow-up period. For early AF recurrence male sex was a significant risk factor (p=0.028) with an odds ratio 8627 (CI 95% 1261-59,006). CONCLUSIONS: The low sinus rhythm rate at discharge and high rates of recurrence may be attributed to the disease nature. Males are at increased risk of early AF recurrence but no significant risk factors for late recurrence have been found.

Determinants of mortality in patients requiring prolonged intensive care unit stay after elective isolated on-pump coronary artery bypass grafting surgery.

BACKGROUND: In up to 36% of patients undergoing cardiac surgery prolonged intensive care unit stay may be necessary. Mortality rates of these patients range from 11% to 94%, causing enormous clinical and ethical issues. AIM: To identify preoperative, perioperative and postoperative risk factors of mortality in patients with prolonged intensive care unit stay after elective, isolated on-pump coronary artery bypass grafting surgery. METHODS: Clinical data of 137 patients who underwent an elective, isolated on-pump coronary artery bypass grafting operation, and had an intensive care unit stay of > or = 3 days were retrospectively evaluated. Survivors and non-survivors were compared with regard to preoperative, perioperative and postoperative characteristics to identify the risk factors for mortality. RESULTS: Multivariate analysis demonstrated that diabetes mellitus (OR = 3.62, 95% CI 1.07-12.26, p = 0.039), postoperative renal dysfunction (OR = 3.86, 95% CI 1.26-11.75, p = 0.018), postoperative intra-aortic balloon pump use (OR = 3.47; 95% CI 1.01-13.24, p = 0.048), prolonged intubation (OR = 3.90, 95% CI 1.19-12.69, p = 0.024) and re-intubation (OR = 14.83, 95% CI 4.35-50.55, p = 0.001) were significant and independent risk factors of mortality. CONCLUSION: The present study found that the preoperative presence of diabetes mellitus, and postoperative multiorgan failure syndrome decreased the probability of survival in patients with prolonged intensive care unit stay after elective isolated on-pump coronary artery bypass surgery.

Off-pump coronary artery bypass surgery can be completed safely in high risk patients.

BACKGROUND: Off-pump coronary artery bypass (OPCAB) grafting has the potential to reduce morbidity and mortality, compared to on-pump cardiac surgery. AIM: We compared the early results of OPCAB lateral and posterior wall revascularisations in 'low', 'intermediate' and 'high' risk patients as defined by the EuroSCORE system. METHODS: Eighty-nine patients who underwent OPCAB with lateral and posterior wall revascularisation from January 2006 to December 2008 were included in this study. Patients were allocated to one of the three risk groups according to the EuroSCORE system: low, moderate and high risk groups. Perioperative and early postoperative results of the three groups were compared. RESULTS: Significantly fewer patients required prolonged ICU stay in the low risk group, compared to moderate (19.4 vs. 50%) and high risk groups (19.4 vs. 36.7%). In addition, prolonged mechanical ventilation was more common in moderate (39.3 vs. 9.7%) and high risk groups (36.7 vs. 9.7%), compared to the low risk group. However, the groups did not differ in terms of mortality or other perioperative outcomes. CONCLUSIONS: Our results suggest that in patients who are considered high risk on the basis of the EuroSCORE model and have diseased vessels on the lateral and/or posterior walls of the heart suitable for grafting, the early outcomes with OPCAB are similar to those in medium or low EuroSCORE risk category. The EuroSCORE model may overestimate the risk for OPCAB procedures.

Increasing numbers of penetrating cardiac trauma in a new center.

BACKGROUND: Our aim was to express the importance of emergency diagnosis and surgical approach in penetrating cardiac trauma patients. METHODS: Kosuyolu Heart and Research Hospital moved to its new location in Cevizli Kartal in June 2005. Due to its close proximity to the main roads of the city, the number of trauma cases has increased tremendously. We have retrospectively examined our penetrating cardiac trauma cases treated between June 2005 and September 2008. RESULTS: Twenty-six trauma cases were admitted to our clinic with penetrating cardiac trauma. Twenty of them were operated on an emergency basis. One (5%) had a gunshot wound while the other 19 (95%) had stab wounds. Four were female (20%) and 16 were male (80%). Average age of the patients was 24.9+/-10.1 (12-49) years. Telecardiography and transthoracic echocardiography were used for diagnosis. Surgical approaches were median sternotomy in 14 and left anterolateral thoracotomy in 6 cases. The right ventricle was damaged in 12, left ventricle in 7 and pulmonary artery in 1. Additionally, 5 patients had lung injury, 1 had brachiocephalic vein injury and 1 had coronary artery injury. One patient was re-explored for bleeding. There were two mortalities (10%) postoperatively. CONCLUSION: Rapid transfer to the emergency department, accurate and quick diagnosis and aggressive surgical approach will increase survival in penetrating cardiac trauma.

An inferior mesenteric artery aneurysm in a patient with renal cell carcinoma.

An inferior mesenteric artery aneurysm is considered one of the visceral artery aneurysms, which is extremely rare, although its incidence of detection has been increasing in recent years. A 59-year-old male patient with a renal cell carcinoma in the left kidney was diagnosed with an inferior mesenteric artery aneurysm and treated surgically. Computed tomography revealed atrophy of the right kidney and occlusion of the celiac trunk, superior mesenteric artery, and left renal artery. There were no complications during the hospital stay and no mortality or morbidity was observed at three months of follow-up. In conclusion, the treatment of inferior mesenteric artery aneurysms is usually recommended, due to possible complications such as rupture and thromboembolism with high mortality and morbidity rates.

Thrombophilias and arteriovenous fistula dysfunction in maintenance hemodialysis.

Most episodes of fistula thrombosis are consequences of underlying physioanatomic abnormalities. However, some dialysis access thrombosis develops independent from any obvious anatomic cause. We aimed to clarify the role of thrombophilias in primary and secondary AVF failure. One hundred eighty nine arteriovenous fistulas in 116 adults on maintenance hemodialysis were analyzed. All subjects were evaluated for many thrombotic factors. Fistula information was obtained both from the patients' self reports, and from their medical records. Twenty-seven AVFs in 18 cases (14.3%) had pAVFF. The percentage of subjects with a BMI < 20 kg/m(2) was significantly lower than no-pAVFF group (P = 0.03). ATIII levels and albumin values were significantly lower in patients with sAVFF compared to those with no sAVFF. Other parameters were similar. There was no statistically significant difference between pAFFF versus No-pAFFF and sAFFF versus No-sAFFF groups with respect to all mutant alleles count. Routine extended analyses of all thrombophillic factors are not recommended in AVFF.

A highly fatal intraoperative urgency--aortic dissection complicating heart surgery.

BACKGROUND: Aortic dissection is associated with high mortality. Despite its rarity, it is often fatal. AIM: We have retrospectively analysed acute aortic dissections occurring intraoperatively (IAAD). METHODS: Patients' preoperative risk factors, and operative and postoperative courses were analysed from the hospital records retrospectively. RESULTS: From 1985 to 2009, we performed 29 683 cardiac operations. Ten patients (0.43 per thousand) (mean age 66.5+/-7 years) were diagnosed with IAAD. There were type 2 dissections in 9 and one patient had it extending beyond the arcus. Four patients were operated on for coronary artery disease, 2 for mitral and 2 for aortic valve diseases. Two patients had concomitant valvular or valvular and coronary procedures. IAAD was identified after decannulation in 5, after creating the holes for proximal anastomoses in 3 and after declamping the aorta in 2 patients. Preoperatively, 6 (60%) patients had hypertension and 4 had hypercholesterolaemia (40%). No other significant risk factors could be identified. Hypothermic circulatory arrest was used in 6 operations. The dissected segment was replaced with a graft in 9 patients whereas the remaining patient had concomitant arcus aorta replacement and elephant trunk procedure. Aortoplasty with Dacron patch was used in one patient. All patients required inotropic and 4 patients IABP support postoperatively. Three (30%) patients died. CONCLUSIONS: The IAAD may occur in any patient at any phase of cardiac surgery. The surgeon should always be aware of the possibility of this complication. It is much better to prevent the IAAD than to treat it. When detected, abrupt change of the operation plan and reparative measures for the dissection should be undertaken.

[Mid-term results of surgical radiofrequency ablation for permanent atrial fibrillation]. / Kalici atriyal fibrilasyonun cerrahi radyofrekans ablasyon ile tedavisi: Orta dönem sonuçlarimiz.

OBJECTIVES: Atrial fibrillation (AF) is a common problem in cardiac surgery patients. We evaluated the mid-term results of patients who underwent open heart surgery and radiofrequency ablation (RFA). STUDY DESIGN: The study included 79 patients (53 females, 26 males; mean age 53+/-11 years; range 32 to 76 years) who underwent concomitant RFA for AF during open heart surgery under cardiopulmonary bypass. The majority of patients were in NYHA class III (n=68, 86.1%) and had (n=67, 84.8%) rheumatic heart disease. The mean preoperative AF duration was 47+/-41 months. The most frequent procedure involved the mitral valve (64 replacements, 11 reconstructions). A unipolar probe was used in 60 patients (76%) and a bipolar probe in 19 patients (24.1%). The mean follow-up period was 20.8+/-14.7 months (range 1 to 59 months). RESULTS: The mean perfusion and cross-clamp times were 102.4+/-15.7 min (range 48 to 171 min) and 76.1+/-25.0 min (range 27 to 145 min), respectively. In-hospital mortality occurred in two patients (2.5%) and late mortality occurred in three patients (3.8%). One patient (1.3%) required implantation of a permanent pacemaker. During discharge, 58 patients (73.4%) were in sinus rhythm, of which nine (15.3%) developed recurrent AF within a mean of 5.3+/-4.4 months (range 2 to 12 months). Transient atrial flutter was seen in three patients (3.8%). Logistic regression analysis showed no risk factor to significantly affect early or late AF recurrence. Six- and 12-month rates of AF-free rhythm were 94.3+/-3.9% and 87.6+/-5.9% for operations performed by the year 2006 and 95.2+/-3.3% and 92.2+/-4.4% afterwards, respectively (p=0.0001). There was no significant difference with respect to survival between patients discharged with AF and in sinus rhythm (p>0.05). CONCLUSION: Radiofrequency ablation is increasingly performed for the treatment of AF, yielding more successful results.