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.

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.

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.

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.

The preventive role of the posterior pericardial window in the development of late cardiac tamponade following heart valve surgery.

OBJECTIVES: It is reported that creating a window from the posterior pericardium into the left pleural cavity during coronary bypass surgeries reduces postoperative late cardiac tamponades. Although late tamponades are more common after heart valve surgeries, this procedure is not generally performed. The present study investigated whether creating a window has a preventive effect on the formation of late cardiac tamponade after heart valve surgeries. METHODS: The study was conducted on all patients (n = 262) in whom one or more valves were replaced and who fulfilled the study criteria between January 2010 and October 2014 in one centre. We began to create a posterior pericardial window in all valvular patients from March 2012. One hundred and thirty-five patients operated on before this date (Non-Window Group) and 127 patients after this date (Window Group) were compared for the development of late cardiac tamponade. RESULTS: There were no differences between the groups in terms of preoperative and intraoperative characteristics. Late pericardial tamponade was not observed in any patients from the Window Group, whereas it occurred in 7 (5.2%) patients from the Non-Window Group (P = 0.015). Three patients died in total; all 3 were from the Non-Window Group. One of the mortalities was associated with tamponade. CONCLUSIONS: Creating a pericardial window may reduce late cardiac tamponade events/episodes, which may be a fatal complication in valve patients. We recommend performing this procedure by allocating some time during the surgical procedure in order to avoid tamponade.

Sequential radial artery grafting three-vessel coronary artery disease.

Our objective was to compare the results of revascularization by sequential radial artery (RA) grafting with a left anterior descending left internal mammary artery (LIMA)-RA t-composite grafting technique. Patients were grouped as those with proximal anastomoses performed on the ascending aorta (Group A; n = 38), and those with proximal anastomoses performed on the LIMA as t-grafts (Group T; n = 13). Neither of the two groups revealed any mortality. The average number of grafts was lower in Group T (2.23 +/- 0.43 in group T and 2.85 +/- 0.69 in group A, p < 0.05). The results of the control coronary artery angiographies were superior in Group A. The patency rate of the RA grafts was 96.8% in Group A. Of the 20 distal anastomoses performed with RA grafts in 8 patients from Group T, nine (45%) were found to be patent. The patency rates of RA grafts with sequential distal anastomoses were found to be better when the proximal anastomosis was performed on the ascending aorta rather than on the LIMA. In conclusion, sequential distal anastomosis of RA grafts seem to be safe and effective when proximal anastomoses are performed on the ascending aorta.

Evolution of repaired and non-repaired tricuspid regurgitation in rheumatic mitral valve surgery without severe pulmonary hypertension.

The aim of this study was to evaluate the usefulness of repairing significant tricuspid regurgitation (> or = grade 2) without severe pulmonary hypertension (< or = 50 mm Hg). Between 1993 and June 2001, 88 consecutive patients were operated on for rheumatic mitral valve disease associated with significant tricuspid regurgitation and without severe pulmonary hypertension. The severity of the tricuspid valve disease was assessed by echocardiography. Sixty-three patients had severe (> or = grade 3) tricuspid regurgitation (Group I), and 25 patients had moderate (grade 2) tricuspid regurgitation (Group II). There was no hospital mortality. six patients died during follow-up. The overall actuarial survival rate for 8 years was 92.1% +/- 3.1%. Cox proportional hazard regression analysis showed that age ( p = 0.006) and pulmonary complication ( p = 0.01) were associated with increased late mortality. Freedom from death was similar in both groups at 8 years (93.1% +/- 3.3% versus 88% +/- 8%, p = 0.7). Severe postoperative tricuspid regurgitation (> or = grade 3), caused by the failure of tricuspid repair or leaving the valve untouched, impaired long-term survival after surgery, and actuarial survival was 96.1% +/- 2.7% and 83% +/- 7.8% at 7 years ( p = 0.048), respectively. Severe tricuspid regurgitation, functional or organic, should be corrected at the time of mitral valve surgery, whereas untouched functional moderate tricuspid regurgitation improves after mitral valve surgery.

Diagnostic value of hemoglobin A1c and fasting plasma glucose levels in coronary artery bypass grafting patients with undiagnosed diabetes mellitus.

BACKGROUND: Early detection, diagnosis, and treatment of diabetes are of utmost importance in preventing diabetic complications and improving short- and long-term outcomes in patients undergoing coronary artery bypass grafting surgery. The aim of this study was to evaluate the ability of preoperative hemoglobin A1c (HbA(1c)) measurement, either alone or in combination with fasting plasma glucose (FPG), to detect glycometabolic disturbances among patients undergoing elective on-pump coronary surgery. METHODS: A total of 166 patients who underwent elective isolated on-pump coronary surgery were included. Hemoglobin A1c and 8-hour FPG measurements were obtained by venous blood sampling on the day before the operation. After 1 month, an oral glucose tolerance test was performed in all discharged patients without known diabetes. The sensitivity and specificity for the diagnosis of diabetes were analyzed for FPG, HbA(1c), and for the combined use of HbA(1c) and FPG, in reference to the tolerance test results. RESULTS: Sixty percent of patients without known diabetes were diagnosed as diabetes or prediabetes with glucose tolerance test. Compared with either test alone, combined use of FPG and HbA(1c) had higher sensitivity and specificity. Positive predictive values for FPG, HbA(1c), and combined use of these two factors were 83.6%, 94%, and 97%, respectively. The combined use had a sensitivity and specificity of 84.4% and 94.1%, respectively. CONCLUSIONS: Fasting plasma glucose alone does not seem sufficient for diagnosing approximately half of the patients with dysglycemia. Our results suggest that the use of FPG and HbA(1c) measurements in combination may be a useful strategy to preoperatively identify coronary patients with unknown diabetes.

Comparison of figure-of-eight and simple wire sternal closure techniques in patients with non-microbial sternal dehiscence.

OBJECTIVE: Sternal dehiscence is a serious and potentially devastating complication. The present study compared the effects of two sternal closure techniques, simple wire technique and figure-of-eight technique, on the development and outcome of non-microbial sternal dehiscence. METHODS: Medical records of all adult patients (n=6211) that underwent cardiac operations in our clinic through median sternotomy between January 2002 and August 2008 were retrospectively reviewed for the development of non-microbial sternal dehiscence. The outcomes of 90 (1.44%) isolated on-pump coronary artery bypass surgery (CABG) cases that developed dehiscence were analyzed with Student's t test, Mann Whitney U test, Chi-square test and Fisher's Exact test according to the type of sternal closure: figure-of-eight or simple wire technique. Survival analysis was made with Kaplan Meier test. RESULTS: Figure-of-eight and simple wire technique were associated with similar rates of sternal dehiscence (1.46% and 1.43%, respectively). In addition, after the development of sternal dehiscence, these techniques were associated with similar mortality rates and postoperative outcomes (time to sternal re-fixation, prolonged ICU stay, intraaortic balloon counterpulsation use and chest re-exploration inotropic agent use and postoperative cerebrovascular accident). One patient died in each group (2.6% vs. 1.9%, respectively). CONCLUSION: In conclusion, present findings suggest that the most commonly used sternal closure techniques, figure-of-eight technique and simple wire technique, may have similar outcomes in terms of development and prognosis of non-microbial dehiscence in patient undergoing isolated on-pump CABG operations.

Ring annuloplasty in chronic ischemic mitral regurgitation: encouraging early and midterm results.

Ischemic mitral regurgitation, a complication of myocardial infarction, is associated with a poor prognosis and can result in postinfarction congestive heart failure. The preferred treatment of its chronic form is a matter of debate. Herein, we report the early and midterm results in 44 patients with chronic ischemic mitral regurgitation in whom concomitant mitral ring annuloplasty and coronary revascularization were performed at our hospital. We reviewed their medical records. The patients had grades 3/4 and 4/4 chronic ischemic mitral regurgitation, or grade 2/4 regurgitation with left ventricular dilation and low left ventricular ejection fraction. All received circular, flexible annuloplasty rings. Four patients died during the early postoperative period due to low cardiac output (9.1%). At the last follow-up echocardiographic examinations, performed a mean 13.14 +/- 4.66 months after the surgical procedures (range, 6-22 mo), the 40 surviving patients were found to have significantly reduced left ventricular end-diastolic (P = 0.029) and end-systolic (P < 0.05) diameters and improved New York Heart Association functional class (P = 0). Despite a risk of residual regurgitation, mitral ring annuloplasty appears to be a good treatment alternative in selected patients who have chronic ischemic mitral regurgitation. We discuss the procedure's rate of hospital mortality, and its potentially positive impact on survival.