Bahadir Gultekin

Diaphragmatic paralysis after cardiac surgery in children: incidence, prognosis and surgical management.

Diaphragmatic paralysis (DP) after cardiac surgery is an important complication especially in infants. We analyzed the incidence, clinical course, surgical management and follow up of the patients with DP, retrospectively. Between 1996 and 2005, 3,071 patients underwent cardiac surgery. Total number of patients with DP was 152 (4.9%). Out of 152 patients, 42 were surgically treated with transthoracic diaphragm plication (1.3%). The overall incidence of diaphragm paralysis was higher in correction of tetralogy of Fallot (31.5%), Blaloc–Taussig (B–T) shunt (11.1%) and VSD closure with pulmonary artery patch plasty (11.1). The incidence of DP which require plication was higher in B–T shunt (23.8%) arterial switch (19%) and correction of tetralogy of Fallot (11.9%). Mean and median age at the time of surgery were 17.8±3.6 and 6 months, respectively. Median time from cardiac surgery to surgical plication was 12 days. Indications for plication were repeated reintubations (n=22), failure to wean from ventilator (n=12), recurrent lung infections (n=5) and persistent respiratory distress (n=3). Mortality rate was 19.1%. Being under 1 year of age, pneumonia and plication 10 days after mechanical ventilation were associated with higher incidence mortality (P<0.05). Phrenic nerve injury is a serious complication of cardiac surgery. It is more common after some special procedures. Spontaneous recovery is very rare. Being under 1 year of age, plication after 10 days from the surgery and pneumonia are major risk factors for mortality even in plicated patients. Transthoracic plication is helpful if performed early.

Mitral Valve Replacements in Redo Patients with Previous Mitral Valve Procedures: Mid‐Term Results and Risk Factors for Survival

Abstract  Objective: We aimed to investigate the risk factors for hospital mortality, short (five years) and mid‐term (10 years) survival in patients who underwent mitral valve replacements in redo patients with previous mitral valve procedures. Patients and Methods: Between September 1989 and December 2003, 62 redo patients have undergone mitral valve replacements due to subsequent mitral valve problems. Preoperative, operative, and postoperative data were analyzed retrospectively and evaluated for risk factors affecting hospital mortality, mid‐ and long‐term survival. Results: The hospital mortality was 6.4%. The one‐, five‐, and 10‐year actuarial survival rates were 94%± 2%, 89%± 6%, and 81 ± 9%. New York Heart Association (NYHA) functional class IV, low left ventricular ejection fraction (<35%), increased left ventricular end‐diastolic diameter (LVEDD) > 50 mm, female gender, pulmonary edema, and urgent operations were found to be risk factors in short‐term survival. NYHA functional class IV, low left ventricular ejection fraction, increased LVEDD, and increased left atrial diameter (LA > 60 mm) were risk factors in mid‐term survival. Conclusion: Redo mitral valve surgery with mechanical prosthesis offers encouraging short‐ and mid‐term survival. NYHA functional class IV, low left ventricular ejection fraction, and increased left ventricular diameters were especially associated with increased short‐ and mid‐term mortality. Earlier surgical management before the development of severe heart failure and myocardial dysfunction would improve the results of redo mitral valve surgery.

Successful Cardiac Transplantation From Donor With Carbon Monoxide Intoxication: A Case Report

BACKGROUND The use of hearts for cardiac transplantation from donors with brain death due to exposure to high concentrations of carbon monoxide is still under discussion. In this short report we have presented a patient who underwent a successful cardiac transplantation from a brain-dead donor who had cardiopulmonary resuscitation after carbon monoxide intoxication. METHOD A standard biatrial anastomosis technique was used in our patient. The transplantation was uneventful with donor ischemic time of 180 minutes. The patient was treated with mechanical ventilation for 72 hours. The donor liver biopsy during harvesting did not reveal irreversible changes. Although the donor had a history of cardiopulmonary resuscitation, the left ventricular ejection fraction was 55% and the echocardiographic evaluation revealed normal cardiac contractions with acceptable hemodynamic parameters. Positive inotropic support was needed in the early postoperative period. We did not observe any changes related to intoxication in the endomyocardial biopsy. CONCLUSIONS We concluded that successful heart transplantation can be performed using hearts from patients succumbing to carbon monoxide poisoning in the presence of adequate cardiac functional parameters. This group will increase the number of cardiac transplantations and decrease the incidence of deaths among patients on transplantation lists.

The Role of Antiendothelial Cell Antibodies in the Development and Follow-up of Coronary and Peripheral Arterial Diseases

Occlusive lesions in the arterial endothelium are often caused by formation of intimal hyperplasia and fibrinoid necrosis. The objective of this study was to investigate the association between antiendothelial cell antibodies (AECAs) and the development of coronary artery disease (CAD) and peripheral artery disease (PAD). In this study, 94 patients with CAD or PAD and 94 healthy volunteers serving as control subjects were examined. Frozen sections of human umbilical vein endothelial cells and primate smooth muscle cells were used to detect the presence of AECAs, which were found in 52 of 94 patients (55%) and in 15 of 94 controls (16%) (P < .001). Endothelial structure tissue damage is a major factor in arterial diseases. In the present study, a statistically significant relationship was found between AECAs and the development of CAD and PAD. The presence of AECAs has been identified as a risk factor for these diseases. According to this study, AECAs are reliable prognosticators for the development of CAD and PAD. Further studies with large numbers of serum samples are under way.

The Midterm Results of Cardiac Transplantation Patients

OBJECTIVE Cardiac transplantation is an important treatment option that increases the survival and decreases the limitations in effort capacity among patients with end-stage heart disease. In this study we have presented the midterm results of 13 patients who underwent cardiac transplantation between 2003 and 2007. PATIENTS AND METHODS There were 10 male and three female patients of mean age of 32 +/- 13.27 years (12 to 54). In one patient, we performed combined cardiac and renal transplantation. Ischemic cardiac disease was present in six patients and cardiomyopathy in seven patients. The mean age of the donors was 23.3 +/- 11.8 years (12 to 46). Corticosteroids, cyclosporine, and mycophenolate mofetil were used for immunosuppression. Sirolimus was employed in five cases due to impaired renal function. Patients were followed by echocardiography, endomyocardial biopsy, and dobutamine stress echocardiography. RESULTS The mean follow-up was 18.6 +/- 13.4 (1 to 38) months. In four patients, there was grade IIIA (II-R) rejection. In five patients, tacrolimus or cyclosporine was replaced with sirolimus due to elevated creatinine levels. Dobutamine stress echocardiography was positive in one patient, who displayed a severe left main coronary artery lesion. There was no operative mortality. There was only one hospital mortality (7.6%). Two patients died in the midterm. The overall mortality on follow-up was 3 (23.1%). The survival rates in the first, second, and third years were 92%, 88%, and 75%, respectively. Ejection fraction were more than 50%; all of posttransplant survivors showed good effort capacity. CONCLUSION Cardiac transplantation is a definitive, safe, and effective treatment for patients with end-stage heart failure.

Regional anesthesia in elderly patients undergoing carotid surgery: report of a case series.

Background: This study evaluates the short-term results in patients more than 75 years of age undergoing carotid endarterectomy at a single institution. Methods: Between June 2004 and June 2007, carotid endarterectomy operations were performed in 123 patients. A total of 70 patients had regional anesthesia. The data for all patients were retrospectively reviewed. Regional anesthesia and selective shunting was performed in all patients. Results: In 6 patients, a shunt was required. Primary closure of the carotid artery was performed in 22 patients and patch angioplasty was used in the remainder. There were no postoperative neurological complications. One patient died due to myocardial infarction. Conclusions: Carotid endarterectomy with regional anesthesia can be performed safely in the elderly population with low mortality and morbidity. Regional anesthesia may have advantages over general anesthesia and could potentially aid in avoiding complications related to shunt use.

HLA Sensitization in End-Stage Heart Failure Patients Supported By Extracorporeal Membrane Oxygenation

Introduction Human leukocyte antigen (HLA) sensitization of heart recipients increases the risk for dysfunction of the cardiac allograft. HLA sensitization rates on extracorporeal membrane oxygenation (ECMO) are unclear. In this retrospective study, we sought to define the possible factors that may induce HLA sensitization in the heart transplant recipients where ECMO bridge to transplantation was employed. Materials and Methods This was a single-center retrospective review in which 23 patients who were supported with ECMO were analyzed. Data on pre-transplant ECMO patients (14-51 years) included: age; diagnosis, duration of mechanical support; use of blood products, volume of transfusion; level of screening panel-reactive antibodies (PRAs); and outcome. PRA>25% was used to define HLA sensitization in both HLA type I and II while PRA>90% was used for highly-sensitized patients. Results 8 patients (34%) became sensitized after ECMO support. The duration of ECMO showed variation between 5 was 21 days. The volume of blood products transfused was 294 ml. Factors like; diagnosis, age and duration of mechanical support did not appear to be linked to HLA sensitization. However, the volume of transfused blood products has been found to be associated and could give rise to HLA sensitization. Conclusion Different studies have shown an increased risk for acute graft failure among patients with elevated pre-transplant anti-HLA antibodies, but others have not. HLA sensitization does occur rarely in ECMO supported patients and may be associated with the large amounts of blood products received during ECMO. Although sensitization may occur, successful transplantation is possible without any evidence of rejection. With increasing number of patients being bridged to heart transplantation, further research is needed to clearly define the significance of allosensitization on ECMO and establish a clear etiology of all factors related.

Left Ventricular Assist Device Management Strategy

Introduction Heart transplantation is the gold standard treatment for end-stage heart failure. The use of left ventricular assist devices (LVAD) is increasing due to the large number of transplant candidates and donor organ limitation. In the final consensus, the LVAD velocities are adjusted according to the interventricular septum position and aortic valve opening frequency. In this study, we aim to present the parameters that we use in patients with LVAD and to find out the answer to the question whether we can recognize in advance the development of right ventricular failure, especially in the context of these parameters. Materials and Methods 62 patients who had LVAD implantation in our clinic between April 2013 and November 2017 were evaluated. Our routine LVAD follow-up includes physical examination findings (hepatomegaly and pretibial edema), LVAD parameters (speed, power, flow), renal and liver function tests, and prothrombin time. Interventricular septum position, right ventricular end diastolic (RVED) and end-systolic diameters and volumes, right ventricle (RV) diastolic and systolic areas, ratio of the short axis of the RV to the long axis of the RV, RV fractional areas, inferior vena cava diameter and association with respiration, tricuspid annular plane systolic excursion (TAPSE), left ventricular end-diastolic (LVED) and end-systolic diameters and volumes and aortic valve expansions were assessed by echocardiography. Results We decided not to use only septum position and aortic valve opening parameters in order to adjust the LVAD rate but looking at all of the parameters mentioned above. In a patient with a volumetric load, although the septum is in the midline, we have found that the LVED diameters and volumes and RVED diameters and volumes have increased compared to the previous findings. Instead of increasing pump flow rates in these patients, we arranged diuretic treatments. The increase in the ratio of the short axis to the long axis of the RV, the RV fractional area and the inferior vena cava diameter was determined as cautionary parameters for developing right ventricular failure. Discussion Various invasive and non-invasive methods are available for optimal adjustment of the speed of the LVAD. Echocardiography is one of the non-invasive methods. Intermittent aortic valve opening and septum position are assessed with echocardiography when LVAD velocity is set. However, these parameters alone may not be enough to evaluate the right ventricular failure that may occur due to long-term use of the device (destination therapy), and may lead to missed sight. Conclusion A complete patient follow-up chart including aortic valve opening and septum position together with LVED volumes and diameters and RV parameters helps to reduce the error margin to a minimum and helps us to organize our treatment strategy.

Unusual Treatment of Unusual Complication: Stenting of Left Ventricular Assist Device Outflow Graft Stenosis

Due to the increase in the number of patients waiting for heart transplantation and shortage of heart donors, both the use of mechanical assist devices and their associated complications increase. Here we present the case of a stenosis occurring in a patient at aortic outflow graft anastomosis for whom we applied a left ventricular assist device, followed by a discussion of the diagnosis, approach, and the treatment we offer in our clinic.

[Fistula between the left internal mammary artery and pulmonary artery: a rare cause of recurrent angina after coronary bypass grafting].

Left internal mammary artery (LIMA) to pulmonary vasculature fistula is a rare complication after coronary artery bypass surgery. In most cases, the duration between bypass grafting and fistula formation ranges from 2 to 5 years. We present a 62-year-old man who presented with anginal symptoms five years after bypass surgery. On coronary angiography, selective catheterization of the LIMA showed fistula formation to the pulmonary artery, which probably led to coronary steal syndrome and myocardial ischemia. He underwent surgery and the connection between the LIMA and pulmonary artery was terminated. After surgery, his anginal complaints improved and echocardiography showed improvement in the wall motion abnormality detected before surgery.