Basar Sareyyupoglu

Surgical Treatment of Saphenous Vein Graft Aneurysms After Coronary Artery Revascularization

BACKGROUND Saphenous vein graft (SVG) aneurysms (SVGAs) after coronary artery bypass grafting (CABG) occur rarely. Most reports are anecdotal. To determine early and late outcomes of surgical treatment, we reviewed our experience with management of this rare complication of surgical revascularization. METHODS From July 1975 to October 2007, 16 patients (15 men), mean age, 60.9 +/- 14.6 years, underwent repair of aortocoronary SVGAs. RESULTS Chest pain was present in 11 of 16 patients. The rest were asymptomatic. The average maximum diameter of the SVGA was 64 +/- 30 mm. The concern of SVGA rupture was the primary indication for operation in 9 patients (56%). Repair in the remaining patients occurred during other cardiac operations. A pseudoaneurysm (75%) at the body or anastomotic sites of the SVG was the most common cause of SVGA. In 8 patients (50%), the aneurysm involved SVG anastomotic sites. Thirteen patients (81%) had intraluminal thrombi. Vein grafts with aneurysm were patent in 9 patients (56%). Surgical procedures included excision of the aneurysm and direct distal coronary target vessel revascularization in 10 (63%), excision and interposition vein graft in 5 (31%), and exclusion by ligation in 1 (6%). Median follow-up was 7 years (maximum, 20 years). Survival was 83% at 5 years and 72% at 10 years after SVGA repair. CONCLUSIONS Ischemic symptoms often accompany SVGA, and operation is indicated to prevent rupture. Ligation or excision of SVGA with simultaneous revascularization appears to be the optimal therapy, with satisfactory midterm and long-term results.

A More Aggressive Approach to Emergency Embolectomy for Acute Pulmonary Embolism

OBJECTIVE To examine operative outcomes after acute pulmonary embolectomy (APE), a recently adopted, more aggressive surgical approach. PATIENTS AND METHODS We retrospectively identified patients who underwent surgical APE from April 1, 2001, through March 31, 2009, and reviewed their clinical records for perioperative outcome. Operations were performed with normothermic cardiopulmonary bypass and a beating heart, absent a patent foramen ovale. For completeness, embolectomy was performed via separate incisions in the left and right pulmonary arteries (PAs) in 15 patients. RESULTS Of the 18 patients identified, the mean age was 60 years, and 13 patients (72%) were men. Thirteen patients (72%) had been hospitalized recently or had systemic disease. The preoperative diagnosis was established by echocardiography or computed tomography (or both). The median (range) follow-up time for all surviving patients was 16 months (2-74 months). Indications for APE included cardiogenic shock (n=12; 67%) and severe right ventricular dysfunction as shown by echocardiography (n=5; 28%). Seven patients (39%) had an embolus in transit. Seven patients (39%) experienced cardiopulmonary arrest before APE. Four early deaths (22%) occurred; all 4 of these patients had preoperative cardiopulmonary arrest, and 2 had APE via the main PA only, without branch PA incisions. Two late deaths (11%) occurred. Right ventricular function improved in all survivors. CONCLUSION The results of emergent APE are encouraging, particularly among patients without cardiopulmonary arrest. It should not be reserved for patients in extremis; rather, it should be considered for patients with right ventricular dysfunction that is an early sign of impending hemodynamic collapse.

Management of Mild Aortic Stenosis at the Time of Coronary Artery Bypass Surgery: Should the Valve Be Replaced?

BACKGROUND General consensus favors aortic valve replacement (AVR) for patients with moderate aortic stenosis (AS) undergoing coronary artery bypass graft surgery (CABG); however, the management of similar patients with mild AS is controversial. We therefore investigated such patients to determine incremental risk of concomitant AVR, progression of AS among those undergoing CABG alone, and operative risk of AVR after prior CABG. METHODS Between January 1993 and December 2003, 316 consecutive patients with mild AS (mean gradient >15, <30 mm Hg) underwent CABG only (107) or CABG plus AVR (209). Follow-up was obtained by review of the medical record, the Social Security Death Index, and postal questionnaire. RESULTS The operative mortality was 3.7% for CABG only and 4.3% for CABG plus AVR (p = 1). Survival at a mean of 5.4 +/- 3.6 years was similar. Multivariate predictors of late mortality included comorbid illnesses (Charlson comorbidity score and age-weighted summary of diseases; p = 0.001), small body surface area (p = 0.001), low ejection fraction (p = 0.007), preoperative permanent pacemaker (p = 0.04), and congestive heart failure (p = 0.046), but not AVR. Twenty-three CABG-only patients (21%) underwent subsequent AVR (mean 5.6 +/- 1.8 years) without mortality. Aortic valve replacement at the time of initial CABG (p <0.001) and older age (p = 0.02) were multivariate predictors of freedom from reoperation. CONCLUSIONS Prophylactic AVR for mild AS at CABG does not confer a survival benefit, and the likelihood of requiring AVR after CABG alone is low in the first 5 years. The decision to intervene on the valve is critically dependent upon the incremental operative risk imposed by concomitant AVR and late survival.

Hypercholesterolemia Association with Aortic Stenosis of Various Etiologies

Abstract  Background: Hypercholesterolemia has been found to be associated with aortic valve stenosis and to resemble the inflammatory process of atherosclerosis in many studies. The aim of this study was to investigate the role of hypercholesterolemia in development of aortic valve calcification in different etiologies. Methods: The study included 988 patients with rheumatic, congenital, or degenerative aortic stenosis, who underwent aortic valve replacement at Koşuyolu Heart and Research Hospital between 1985 and 2005. Effects of hypercholesterolemia and high low‐density lipoprotein level on calcific aortic stenosis or massive aortic valve calcification were analyzed for each etiologic group. Results: Both univariate and multivariate analyses revealed that the high serum cholesterol level (>200 mg/dL) was related to massive aortic valve calcification in all patients (p = 0.003). Hypercholesterolemia was linked to calcific aortic stenosis and massive calcification in patients with degenerative etiology (p = 0.02 and p = 0.01, respectively) and it was related to massive calcification in patients with congenital bicuspid aorta (p = 0.02). Other independent risk factors for calcific aortic stenosis and massive calcification in the degenerative group were high low‐density lipoprotein level (>130 mg/dL; p = 0.03 and p = 0.05, respectively) and high serum C‐reactive protein level (p = 0.04 and p = 0.05, respectively). Conclusions: Hypercholesterolemia is related to increased risk of aortic valve calcification in patients with degenerative and congenital etiology. Preventive treatment of hypercholesterolemia could play an important role to decrease or inhibit development of aortic valve calcification.

Model for end-stage liver disease excluding international normalized ratio (MELD-XI) score predicts heart transplant outcomes: Evidence from the registry of the United Network for Organ Sharing

BACKGROUND Hepato-renal function is a valuable predictor of success after left ventricular assist device therapy and heart transplantation. Hence, we analyzed the importance of the Model for End-stage Liver Disease excluding international normalized ratio (MELD-XI) score to outcomes after heart transplant. METHODS Adults undergoing heart transplant from the United Network for Organ Sharing (UNOS) database were identified (1994 to 2014). Individual MELD-XI scores were calculated; patients were stratified by MELD-XI quartiles (Q1 to Q4). Multivariate logistic regression and the Cox proportional hazard model were implemented to determine any association between MELD-XI scores, survival and other outcomes. RESULTS From 39,711 patients undergoing OHT during the study period, MELD-XI score [median 10.7 (interquartile range 7.0 to 14.4)] was calculated for 36,005 patients (76% male and 75% white, 34% Status 1A). Higher MELD-XI scores had higher rates of pre-transplant extracorporeal membrane oxygenation, intra-aortic balloon pump, inotrope use and mechanical ventilation (p < 0.001 for all). Adjusted long-term mortality (median follow-up 8.1 years) was associated with MELD-XI score (hazard ratio [HR] 1.021 [1.016 to 1.026], p < 0.001). The highest MELD-XI quartile was associated with an HR 1.364 [1.255 to 1.482] risk of mortality compared with Q1. MELD-XI score was also associated with increased post-transplant infections (adjusted HR Q4 vs Q1: 1.364 [1.153 to 1.614], p < 0.001), stroke (adjusted HR Q4 vs Q1: 1.410 [1.074 to 1.852], p = 0.013), dialysis (adjusted HR Q4 vs Q1: 3.982 [3.386 to 4.683], p < 0.001), rejection (adjusted HR Q4 vs Q1: 1.519 [1.286 to 1.795], p = 0.003) and prolonged hospitalization (adjusted HR Q4 vs Q1: 1.635 [1.429 to 1.871], p < 0.001). CONCLUSION Hepato-renal dysfunction, measured with MELD-XI score, predicts morbidity and mortality in patients undergoing orthotopic heart transplantation. Etiology of hepato-renal dysfunction should be sought and treated before heart transplantation.

Comparison of Outcomes of Transfemoral Transcatheter Aortic Valve Implantation Using a Minimally Invasive Versus Conventional Strategy.

Some centers, mostly in Europe, have demonstrated the feasibility of a minimally invasive strategy (MIS; i.e., local anesthesia and conscious sedation, performed in the cath laboratory without transesophageal echocardiography guidance). Nonetheless, the experience of MIS for TAVI using both commercially available valves is lacking in the United States. We, therefore, retrospectively studied all transfemoral TAVI cases performed at our institution between March 2011 and November 2014 to assess the safety and efficacy of MIS. Patients were dichotomized according to the strategy (MIS vs conventional strategy [CS]) used for the procedure. One hundred sixteen patients were included in the MIS group and 91 patients were included in the CS group. Baseline characteristics were similar, and procedural success was comparable (99.1% in MIS and 98.9% in CS, p = 1). One intraprocedural death occurred in each group, whereas conversion rates to general anesthesia were low (3.4%). Comparable device success was obtained. Rates of complications and >mild paravalvular leak before discharge were low and comparable. Length of hospital stay was significantly reduced in the MIS (median, 3.0 [2.0 to 5.0] days) compared with than that in CS group (median 6.0 days [3.5, 8.0]). At a median follow-up of 230 days, no significant difference in survival rate was detected (89% vs 88%, p = 0.9). On average, MIS was associated with remarkable cost saving compared with CS (

B-type natriuretic peptide levels and continuous-flow left ventricular assist devices.

16,000/case). In conclusion, TAVI through MIS was associated with a shorter postprocedural hospital stay, lower costs, and similar safety profile while keeping procedural efficacy compared with CS.

Hybrid Approach to Repair of Pulmonary Venous Baffle Obstruction After Atrial Switch Operation

We postulated that postoperative B-type natriuretic peptide (BNP) levels would be reflective of the degree of hemodynamic support rendered by various pump speeds settings (RPM) of continuous-flow left ventricular assist devices (LVADs). Twenty LVAD patients were evaluated prospectively (Jarvik 2000: n = 9, HeartMate II: n = 11). The mean age was 57.7 ± 14.9 years, and 14 were male. B-type natriuretic peptide levels were drawn while the patients were supported on LVADs at variable RPM settings. The RPM settings were correlated with the changes in BNP levels. Eleven patients underwent LVAD implantation for a lifelong support while the rest were as a bridge therapy to transplantation. Four patients required LVAD change out for various causes of pump failure. Postoperative BNP levels decreased dramatically with the initiation of LVAD support. The levels correlated inversely with the degree of hemodynamic support rendered at various RPM settings of the HeartMate II (p < 0.001). Overall, BNP levels decreased significantly in 2 days after RPM increase. We observed a significant inverse correlation between the postoperative BNP levels and the degree of LVAD support. The effective LVAD support seems to result in a marked reduction in BNP levels, and monitoring serial BNP levels may be helpful in managing patients supported on continuous LVAD.

Safety and durability of mitral valve repair for anterior leaflet perforation

Pulmonary venous pathway obstruction is a late complication of the atrial switch operation for transposition of the great arteries. Gaining peripheral access to the pulmonary venous baffle obstruction to treat the obstruction with stent deployment is difficult if not impossible. We present three patients in which we used hybrid procedures in the operating room to relieve the pulmonary venous pathway obstructions.

Intramural Left Main Coronary Artery Unexpectedly Encountered During Aortic Root Replacement

OBJECTIVE We sought to evaluate mitral valve repair for anterior leaflet perforation. METHODS Between October 1987 and October 2006, 26 patients with mitral valve anterior leaflet perforation underwent mitral valve repair (median age, 54 years; 18 [69%] were male). RESULTS The indication for operation was severe mitral regurgitation only in 14 patients, both aortic regurgitation and mitral regurgitation in 11, and ventricular septal defect repair in 1. Twenty-four (92%) patients had endocarditis and 13 (50%) had at least mild aortic regurgitation preoperatively. Left atriotomy was performed in 17 (65%) and aortotomy in 8 (31%). Six (23%) patients had visible vegetations at the time of repair. For anterior leaflet repair, a patch was used in 11 (42%) patients and primary suture closure in 15 (58%). Eighteen patients underwent concomitant cardiac surgical procedures. Postoperative follow-up (mean, 6 years) was available for 25 (96%) patients. There was 1 early death from multiorgan failure and 2 late deaths. Patient survival was 95% at 1 year and 90% at 5 years. Left ventricular end-diastolic dimension improved significantly after mitral valve repair at dismissal (n = 16; -9.4 mm; P < .01) and during follow-up (n = 11; -10.8 mm; P < .01). Only 1 (4%) patient had mitral valve reoperation after 7 years owing to recurrent endocarditis 6 months after repair. CONCLUSIONS Mitral valve anterior leaflet perforation may be safely repaired with good midterm survival and durability.