Cengiz Turkay

Aortoiliac Kissing Stents: Long-term Results and Analysis of Risk Factors Affecting Patency

Purpose: To present the early and long-term results of aortoiliac kissing stents implantation and evaluate the risk factors affecting patency. Methods: The data were retrospectively reviewed on 68 patients (64 men; mean age 55±11, range 32–77) who underwent kissing stents implantation during a 12-year period. The majority of patients (64, 94%) had claudication; 4 patients had rest pain. All were smokers. There were bilateral or unilateral stenoses in 42 (62%) patients, and unilateral occlusion and contralateral stenosis in 26 (38%). Lesions were treated with simultaneous implantation of self-expanding (n=52) or balloon-expandable (n=16) stents. After the procedure, patency was determined with Doppler ultrasonography or angiography at 1, 3, 6, and 12 months and annually thereafter. Primary, assisted primary, and secondary patency rates were calculated with Kaplan-Meier analysis on an intention-to-treat basis, and risk factors affecting the patency rates were determined with the Cox regression analysis. Results: All procedures were technically and clinically successful. Complications occurred in 12%, but none required surgery. The follow-up period was 35±31 months. Primary, assisted primary, and secondary patency rates, respectively, were 76%, 90%, and 94% at 1 year; 63%, 86%, and 92% at 3 years; and 63%, 64%, and 81% at 5 years. In multivariate analysis, age <50 years and presence of iliac occlusion were identified as risk factors for reduced primary and assisted primary patency; a crossed configuration of kissing stents was identified as a risk factor for reduced primary patency. Conclusion: Implantation of kissing stents is a safe and effective alternative in the treatment of aortoiliac obstructions. However, overall primary and assisted primary patency rates are inferior to those reported for surgery. Long-term patency comparable to surgery may be obtained in patients >50 years and in those without an iliac occlusion, particularly if a favorable stent configuration is achieved.

The inhibitory action of protamine on human internal thoracic artery contractions: the effect of free hemoglobin

OBJECTIVE We investigated the mechanism of the protamine action and the effects of free hemoglobin on protamine-induced responses in endothelium-denuded and-intact human internal thoracic artery (ITA) rings precontracted with phenylephrine (PE) or high KCl. METHODS Samples of redundant ITA obtained from patients undergoing a coronary artery bypass graft surgery were cut into 3 mm wide rings and suspended in 20 ml organ baths. Isometric tension was continuously measured with an isometric force transducer connected to a computer-based data acquisition system. RESULTS Acetylcholine (Ach, 10(-8)-10(-5) M) caused a concentration-dependent relaxation of PE-precontracted ITA rings. Free hemoglobin (0.1 and 0.5 microM) produced a concentration-dependent and significant decrease in sensitivity (pD(2)) and maximal contractility (E(max)) in response to Ach in PE-precontracted ITA rings (P<0.0001). Protamine (50-800 microg/ml), free hemoglobin (0.1 and 0.5 microM), nitric oxide (NO) blocker N(omega)-nitro-L-arginine methyl ester (L-NAME, 100 microM) or soluble guanylate cyclase inhibitor methylene blue (10 microM) administration did not cause a significant alteration on basal tonus of endothelium-intact or -denuded ITA rings. Protamine (50-800 microg/ml) induced concentration-dependent relaxation responses in ITA rings precontracted by either PE or high KCl. There was no difference in sensitivity or maximal response to protamine between the endothelium-intact and -denuded rings. Incubation of endothelium-intact or -denuded ITA rings with L-NAME or free hemoglobin or methylene blue did not cause a significant inhibition on relaxation responses to protamine. ITA ring contractions induced by stepwise addition of calcium to high KCl solution with no calcium were almost completely inhibited by protamine (P<0.0001). CONCLUSIONS It was suggested that protamine induced relaxation responses in human ITA rings is not NO- or endothelium-dependent but seems to depend on the interactions of protamine with calcium influxes and/or calcium release from intracellular stores in this tissue.

The effect of pentoxifylline on haemolysis during cardiopulmonary bypass in open-heart surgery.

Objective — Haemolysis has long been recognized as one of the responses to cardiopulmonary bypass (CPB). Pentoxifylline (PTX), a methylxanthine derivative, has been known for many years for its haemorrheological properties. In this prospective, randomized study, we investigated whether a PTX treatment would reduce the haemolysis during CPB. Methods — The effect of PTX treatment on haemolysis during CPB was studied in 25 patients (PTX group). Oral PTX (1200 mg/day in 3 divided doses) treatment for 3 days was followed by 300 mg i.v. PTX administration after anaesthesia induction.The control group consisted of 25 patients with equivalent surgery but no PTX treatment. Blood samples were collected at seven time points: prior to CPB, at 5 and 10 min of CPB and 5, 10 and 15 min after removal of cross clamping and 10 min after weaning from bypass in order to measure the haemolysis parameters, which included free haemoglobin and haptoglobin. Results — PTX-treatment caused statistically significant decrements in plasma free haemoglobin levels during CPB. On the other hand, plasma haptoglobin levels stayed higher in PTX-medicated patients during the CPB as compared to control subjects. Conclusions — These findings suggested that PTX may be an effective agent in reducing the haemolysis during CPB.

Minimally invasive saphenous vein harvesting using a laryngoscope: procedural, functional, and morphologic evaluation.

BACKGROUND Because commercial minimally invasive harvesting equipments significantly increase operation costs, they are not always available in all clinics worldwide. The aim of this study was to investigate whether minimally invasive saphenous vein harvesting using a laryngoscope can be applied efficiently and successfully. METHODS Thirty patients were prospectively randomized into two groups. One group underwent a minimally invasive technique using a laryngoscope; the other, open saphenous vein harvest. A modified bridging technique, in which tissue retraction and illumination is achieved with a sterilized laryngoscope, was used for minimally invasive harvesting. Smooth muscle contractile and endothelial functions were tested in vitro using an organ chamber. Morphology was examined with light microscopy. RESULTS There was no statistically significant difference in harvest times or length of the vein harvested by either of the above mentioned techniques. Total length of the incision in the minimally invasive group was significantly shorter than that in the open group. In follow-ups, no significant complications occurred in either group. Pain and leg edema were significantly less in the minimally invasive group compared to those of the open group. There was no significant difference in response to acetylcholine and 80 mM KCl between veins taken with the laryngoscope compared to veins taken with the traditional open technique. Similarly, histological data was unable to show any significant damage to the vessel wall. CONCLUSIONS Because the laryngoscopic saphenectomy does not harm the harvested graft, it can be applied, instead of other minimally invasive saphenous vein harvesting systems, with a zero cost, efficiently, successfully, and with satisfactory speed and significant reduction of postoperative leg pain and wound complications.

The effect of pentoxifylline on haemolysis in patients with double cardiac prosthetic valves

Objective — Intravascular haemolysis frequently occurs in patients with mechanical heart valve prostheses. In this prospective study, we investigated whether pentoxifylline (PTX) has an effect on haemolysis following prosthetic valvular replacement in 40 patients who underwent double valve (mitral and aortic) replacement. Methods and results — The patients were randomly assigned to two groups as control (n = 20) and PTX group (n = 20). PTX was given in a daily oral dose of 1200 mg (3 times 400 mg) for 120 days. Laboratory tests for evidence of haemolysis namely, haemoglobin (Hb), haematocrit (Hct), plasma total bilirubin, indirect bilirubin and haptoglobin levels, corrected reticulocyte percent and serum lactic dehydrogenase activity (SLDH) were performed before and after the PTX treatment. PTX treatment caused significant increases in Hb, Htc, and haptoglobin levels (P < 0.05, P<0.05 and P<0.01, respectively).Additionally, there were significant decreases in SLDH, total and indirect bilirubin levels, and corrected reticulocyte percent in patients receiving PTX as compared with their respective control values (P<0.01, for all). PTX treatment caused a significant improvement, to different extents, in signs of haemolysis in 60% of the patients. On the other hand, the response rate was 5% in the placebo-treated control group (P<0.05). Conclusions — These findings suggest that PTX may be an effective agent in the management of haemolysis in patients with prosthetic heart valves.

A single coronary artery from the right sinus of valsalva associated with atherosclerosis.

Anomalous origin of the main coronary arteries from the aorta is rare.We report a case with a single coronary artery from the right sinus of Valsalva associated with atherosclerosis. The patient was treated with a coronary artery bypass procedure: left internal mammary artery (LIMA) to the left anterior descending artery (LAD), right internal mammary artery (RIMA) to the right coronary artery (RCA).The postoperative course was uneventful.

Effects of short-term exposure to homocysteine on vascular responsiveness of human internal mammary artery

Abstract: The aim of this study was to investigate the acute direct effects of homocysteine (Hcy) on the vascular responsiveness of human internal mammary artery (IMA) and to define the possible underlying mechanisms. The contractile response to both phenylephrine (Phe) (−36%) and KCl (−18%) was significantly reduced in arteries that were incubated with Hcy (10−4 M, 30 minutes), compared with controls (P < 0.05). Removal of endothelium did not significantly alter the responses of human IMA to Phe. Hcy (10−4 M) also caused a relaxation response in human IMA rings precontracted with Phe (10−6 M) and this effect was not inhibited by Nω-nitro-L-arginine methyl ester (L-NAME, 10−4 M), by l-NAME (10−4 M) + indomethacin (10−5 M), or by intimal rubbing. In addition, contractions induced by stepwise addition to calcium (Ca2+) to high KCl solution with no Ca2+ were significantly inhibited by Hcy incubation as well as contractions induced by Phe in the absence of extracellular Ca2+ (P < 0.05). On the other hand, Hcy (10−4 M, 30 minutes) did not significantly inhibit the relaxation responses to either acetylcholine (ACh) or sodium nitroprusside (SNP) (P > 0.05). These results demonstrated that short-term exposure to Hcy significantly decreased vascular responsiveness in human IMA without affecting endothelium-dependent and -independent vasorelaxation. This effect is not NO-, prostaglandin- or endothelium-dependent. The mechanism is uncertain but seems to depend on the interactions of Hcy with Ca2+ influxes and/or other undefined direct effects in this tissue.

Outcomes and Readmissions After Continuous Flow Left Ventricular Assist Device: Heartmate II Versus Heartware Ventricular Assist Device.

INTRODUCTION Donor organ shortage is still a problem for heart transplantation. Only 10% of patients in waiting list undergo heart transplantation. Over the last 5 years, 2 different continuous flow pumps, the HeartMate II and the HeartWare, have been successful clinically in the alternative treatment of patients with end-stage heart disease. METHODS Fifty-five patients underwent left ventricular assist device implantation between 2011 and 2014. Patients were followed on pump support for complications and intraoperative outcomes. Potential device-related complications include infections, bleeding liver dysfunction, renal dysfunction, right ventricular failure, stroke, thromboembolism, gastrointestinal bleeding, and wound infection. RESULTS The only preoperative significant difference between groups in the study was age; the Heartmate II group were significantly older than Heartware group. There were no differences in gender, body mass index, or body surface area. The Heartware has a better 1-year survival rate, although the difference was not significant. Patients with Heartmate II had a higher incidence of gastrointestinal bleeding and driveline infection. The Heartware group had a higher incidence of stroke and pump thrombosis. CONCLUSIONS The Heartmate II and Heartware are comparable in most respects such as survival, intraoperative features, and major complications.

Surgical treatment of left ventricular aneurysms: a comparison of long-term follow-up of left ventricular function for classic aneurysmectomy and endoaneurysmorrhaphy techniques.

OBJECTIVE Myocardial infarction may be complicated by the formation of a left ventricular (LV) aneurysm that distorts the normal elliptical geometry of the ventricle to produce a dilated spherical ventricle with limited contractile and filling capacities. One of the consequences is congestive heart failure, which may be refractory to medical therapy and require surgical treatment. The aim of this study was to evaluate LV function in the late term following repair of LV aneurysm. METHODS Ninety-seven patients underwent repair of postinfarctional LV aneurysms. Sixty-one patients (62.9%) underwent classic aneurysmectomy, and 36 patients (37.1%) had endoaneurysmorrhaphy. The mean age (+/-SD) of the 87 men (89.7%) and 10 women was 55.98 +/- 8.59 years. Coronary surgery was performed in 82 patients (84.5%), with a mean of 1.34 +/- 0.77 grafts/patient. The mean preoperative ejection fraction (EF) was 39.74% +/- 8.79% (classic, 39.92% +/- 8.90%; endoaneurysmorrhaphy, 39.43% +/- 8.61%; difference not statistically significant [NS]). Fifty-five patients (56.7%) had angina of Canadian Cardiovascular Society class III to IV (classic, 55.7%; endoaneurysmorrhaphy, 58.3%; NS), 31 patients (31.9%) were in New York Heart Association (NYHA) class III to IV (classic, 31.1%; endoaneurysmorrhaphy, 33.3%; NS), and the mean preoperative NYHA functional class was 2.88 +/- 0.74 (classic, 2.83 +/- 0.77; endoaneurysmorrhaphy, 2.97 +/- 0.71; NS). RESULTS The mortality rate at <30 days was 9.8% (n = 6) in the classic aneurysmectomy group and 2.7% (n = 1) in the endoaneurysmorrhaphy group. Long-term follow-up was available for 80 of these patients. During a mean follow-up of 79.3 +/- 37.6 months (range, 6-156 months), 14 patients (17.5%) died of a cardiac-related cause (classic, 8 patients [16.6%]; endoaneurysmorrhaphy, 6 patients [18.7%]; NS). The cardiac-related survival rate was 82.5%. In the first year, at 5 years, and at 10 years, the survival rates of the patients who underwent classical aneurysmectomy were 98.8%, 93.5%, and 76.1%, respectively, and the rates for patients who underwent endoaneurysmorrhaphy were 100%, 93.0%, 71.2%, respectively (P = .2). In the follow-up patient population, the mean preoperative EF was 40.21% +/- 9.44% in the classic aneurysmectomy group and 39.34% +/- 8.61% in the endoaneurysmorrhaphy group. Postoperatively, mean EFs increased to 44.24% +/- 9.50% and 43.80% +/- 8.81%, respectively, at the last follow-up. NYHA functional class changed from 2.79 +/- 0.77 preoperatively to 1.60 +/- 0.73 postoperatively in the classic aneurysmectomy group and from 2.97 +/- 0.71 preoperatively to 1.34 +/- 0.54 postoperatively in the endoaneurysmorrhaphy group. There was no significant difference in hospital readmissions for cardiac causes (classic, 27.1%; endoaneurysmorrhaphy, 31.2%). CONCLUSION LV aneurysm can be repaired with acceptable surgical risk. Surgical treatment of LV aneurysm is associated with an improvement in long-term survival and symptoms.

Extracorporeal Membrane Oxygenation Therapy-Assisted Cardiopulmonary Resuscitation and Successful Bridging to Cardiac Retransplant for Cardiac Allograft Vasculopathy

Extracorporeal membrane oxygenation therapy is being used increasingly in different areas. It has become an indispensable assistant to clinicians for hypoxic pulmonary disorders, cardiogenic shock, resuscitation, and during cardiac surgery. In this case report, we describe a patient who is bridged to successful cardiac retransplant under extracorporeal membrane oxygenation therapy support after extracorporeal membrane oxygenation therapy-assisted cardiopulmonary resuscitation.