Cevat Yakut

Risk Factors for Requirement of Permanent Pacemaker Implantation After Aortic Valve Replacement

Abstractu2002 Background: The aim of this study was to evaluate the frequency of requirement for permanent pacing and related risk factors after aortic valve replacement. Methods: Among 465 patients operated between 1994 and 2004, 19(4.1%) patients with a mean age 49.9 ± 17.2 years required the implantation of a permanent pacemaker. Eleven of them were female (57.9%). The main indication was aortic stenosis (89.5%). Severe annular calcification was documented in 78.9% of them, and the aortic valve was bicuspid in 57.9%. Results: Risk factors for permanent pacing after aortic valve replacement (AVR) identified by univariate analysis were female sex, hypertension, preoperative ejection fraction, aortic stenosis, annular calcification, bicuspid aorta, presence of right bundle branch block (RBBB) or left bundle branch block (LBBB), prolonged aortic cross‐clamp and perfusion times, and preoperative use of calcium channel blockers. Multivariate analysis showed that female sex (p = 0.01, OR; 5.21, 95% CI: 1.48‐18.34), annular calcification (p < 0.001, OR; 0.05, 95% CI: 0.01‐0.24), bicuspid aortic valve (p = 0.02, OR; 0.24, 95% CI: 0.07‐0.84), presence of RBBB (p = 0.009, OR; 0.03, 95% CI: 0.003‐0.44) or LBBB (p = 0.01, OR; 0.13, 95% CI: 0.02‐0.69), hypertension (p = 0.03, OR; 0.22, 95%CI: 0.05‐0.89), and total perfusion time (p = 0.002, OR; 1.05, 95% CI: 1.01‐1.08) were associated risk factors. Conclusion: Irreversible atrioventricular block requiring a permanent pacemaker implantation is an uncommon complication after AVR. Risk factors are annular calcification, bicuspid aorta, female sex, presence of RBBB or LBBB, prolonged total perfusion time, and hypertension.

In Which Patients Should Sheathless IABP be Used? An Analysis of Vascular Complications in 1211 Cases

Abstractu2002 Objective: The purpose of our study is to compare the results of the sheathed and sheathless techniques for intraaortic balloon pump (IABP) insertion and to determine the rate of vascular complications in both conditions. Methods: A total of 1211 patients were examined representing a period of 19 years. Three hundred five sheathless (Group I) and 906 sheathed (Group II) IABP catheters were evaluated retrospectively. Data were analyzed with univariate analysis and logistic regression. Relative risk (RR) values were calculated in order to examine the effect of sheath. Results: Limb ischemia was seen in 129 patients (10.9%). Although the incidence of peripheral arterial disease (PAD) was relatively higher in Group I (11.1% vs. 3.6%), the ischemic complication rate was lower in Group I (5.2% vs. 12.4%; p = 0.001). Presence of PAD (p = 0.001) and diabetes mellitus (DM) (p = 0.007) was found to be the risk factors of ischemia related to IABP use in all cases. In logistic regression analysis, presence of PAD, DM, and sheathed method was found to be the risk factors of ischemia. The patients who had all of these risk factors suffered from limb ischemia (RR value: 35.17). Conclusion: PAD, DM, and sheathed insertion technique are the major risk factors of ischemia during IABP use. Among all these risk factors, the only modifiable risk factor is the use of introducer sheath. With the presence of PAD and DM, the choice of sheathed method would increase the probability of ischemia almost 35 times. Sheathless method of insertion should be preferred in patients with DM and PAD.

Surgical management of cardiac myxoma.

Abstractu2003 Objective: Between 1994 and December 2003, 55 patients were operated for cardiac myxoma in Koşuyolu Heart and Research Hospital in Istanbul. Methods: We retrospectively analyzed our results according to the preoperative characteristics, operative procedures, and postoperative courses. Results: Of 55 patients operated, 36 (65.4%) were female and 19 (34.6%) male. The average age of the patients was 48 ± 15.5 years (range, 12–75). Thirteen patients (23.6%) previously had cerebrovascular accidents. Peripheral arterial emboli had occurred in 11 (20%) patients. The majority of the patients (44.4%) were in NYHA Class II preoperatively. One patient was presented with Carneys complex. Most frequent location was the left atrium (85.2%). Eight patients had concommitant surgery together with myxoma extirpation. Postoperative courses were uneventful. Three patients had a new onset atrial fibrillation, two had transient conduction disturbances. There were two (3.6%) in‐hospital deaths. No recurrences have been noted during the 82.4 ± 40.6 months (a total of 315.75 patient/years) follow‐up. Conclusions: Surgical management of cardiac myxoma gives excellent results. In selected cases, a conservative approach may be adequate. Despite the scarcity of the neoplastic properties, careful follow‐up is necessary.

Coronary artery disease and coronary artery bypass grafting in Behçet's disease.

Abstractu2003 There is a high frequency of pseudoaneurysm formation in patients with Behçets disease and their inflammed and fragile tissues are difficult to manipulate. Five patients with Behçets disease were referred to our cardiovascular surgery department for coronary artery bypass grafting (CABG). Three of them were operated and two were treated medically. Patients that were managed medically had left anterior descending (LAD) lesions below 80% and their stable angina pectoris responded well to medication. There was no early mortality and morbidity. One patient developed pseudoaneurysm of ascending aorta and femoral artery. This patient died in the late postoperative period. At follow‐up the operated patients were in Canadian Cardiovascular Society (CCS) Class I, while the medically treated patients were in CCS Class II. Mean follow‐up period was 41 ± 36.21 months. Coronary artery disease (CAD) is extremely rare detected in patients with Behçets disease. The affected patients are usually young males. Coronary artery bypass grafting is also rarely performed in these patients and long‐term results of such operations are not available in the literature. We present five patients with Behçets disease that had CAD, three operated and two medically treated, and report their long‐term results. We suggest a conservative approach in patients with Behçets disease because of the high risk of pseudoaneurysm formation in the postoperative period. If CABG cannot be avoided we recommend operating the patients on the beating heart with minimal aortic manipulation.

Long-Term Outcome After Total Correction of Tetralogy of Fallot in Adolescent and Adult Age

Abstractu2003 Although most patients with tetralogy of Fallot (TOF) undergo radical repair during infancy and childhood, patients remaining undiagnosed and untreated until adulthood can still be treated. These patients have either a previous palliative or natural collateral circulation to the lung or a mild form of right ventricular outflow tract (RVOT) obstruction. The aim of this study is to analyze the perioperative and long‐term results of radical corrective procedures in patients who reached adult ages. Two hundred and seven patients with TOF underwent complete correction between 1985—and 2002, 64 (30.9%) of whom were aged 14 years or more. The mean age at corrective repair for this group was 20.6 ± 7.5 years (range 14 to 49 years). Only two patients had previous modified Blalock‐Taussig shunts. In 44 patients (68.7%) besides infundibular resection, a transannular gluteraldehyde‐treated pericardial patch was used to reconstruct right ventricular outflow tract (RVOT). Only infundibular patching was used in 15 patients (23.4%) and infundibular muscular resection with primary closure of right ventricle was performed in five patients (7.8%). Hospital mortality was 3.1% with two patients. Four patients (6.2%) underwent reoperation because of recurrent ventricular septal defect (VSD) with/without residual obstruction or pulmonary regurgitation. All survivors were in NYHA class I (42) or II (17). Late mortality was recorded in two patients and 16‐year actuarial survival was 89.2%± 4.9%. The significant negative predictors of late survival determined by univariate analysis were reoperation <0.018) and associated cardiac anomalies <0.011). Multivariate analysis showed that there was no negative predictor of late‐term mortality. Corrective procedures in adult patients with TOF can be performed successfully compared to patients who underwent operation during infancy and childhood.

Biocompatibility of Heparin‐Coated Cardiopulmonary Bypass Circuits in Coronary Patients With Left Ventricular Dysfunction Is Superior to PMEA‐Coated Circuits

Abstractu2003 Background: Several coating techniques for extracorporeal circulation have been developed to diminish the systemic inflammatory response during cardiopulmonary bypass (CPB). The aim of this study was to evaluate the clinical effectiveness and biocompatibility of heparin‐coated and poly‐2‐methoxyethylacrylate (PMEA)‐coated CPB circuits on coronary patients with left ventricular systolic dysfunction. Methods: Thirty‐six patients who underwent elective coronary artery bypass grafting were divided into two equal groups: group H (n = 18), heparin‐coated; group P (n = 18), PMEA coated. Clinical outcomes, hematologic variables, cardiac enzymes, malondialdehyde (MDA), and acute phase inflammatory response (including myeloperoxidase (MPO), catalase, hsCRP, and IL‐8) were analyzed perioperatively. Results: Demographic, CPB, and clinical outcome data were similar for both groups. Plasma fibrinogen, total protein, albumin, and platelet count decreased, neutrophil count, MDA, IL‐8, MPO, and catalase levels increased during CPB. During CPB, MPO and catalase values were significantly higher in group P (p = 0.02 and p = 0.01) and postoperative MDA concentration was lower in group H (p = 0.03). Platelet counts were better preserved in group H during and after CPB but neutrophil count and IL‐8 level did not differ between the groups. Postoperative total protein, albumin, and fibrinogen levels were higher in group H (p < 0.05). The postoperative first day levels of troponin‐I, CK‐MB, and CRP increased in both groups without any significant differences between the groups. Conclusions: Heparin‐coated circuit provided better suppression of perioperative inflammatory markers and exhibited more favorable effects on hematologic variables than PMEA‐coated circuit.

Cardiovascular reoperations in Marfan syndrome.

Abstractu2003 Background and aim of the study: The purpose of this study is to analyze the outcome results of reoperations in Marfan syndrome patients. Methods: Between 1985 and December 2004, 49 patients with Marfan syndrome were operated for aortic aneurysms. Of these 49 patients, 9 (18,4%) required ≥1 reoperations after a mean duration of 32.2 ± 26.6 months. The mean duration of follow‐up was 52.0 ± 46.8 months, a total of 39 patient/years. Survival free of reoperation was calculated by Cox regression analysis. Results: Surgical indication for operation was a chronic aneurysmal dilatation of the ascending or abdominal aorta in seven patients (77.8%) and aortic dissection in two (22.2%) at the initial operation. In the reoperations, repair of thoracoabdominal aortic aneurysm with separated graft interposition in six patients (66.7%), replacement of ascending aorta in one (11.1%), replacement of ascending and hemiarchus aorta in one (11.1%), and mitral valve replacement in three patients (33.3%) were performed. The hospital mortality was 11.1% with one patient. Among the survivors, one expired in the follow‐up five months after the second operation (12.5%). With the Cox regression analysis, survival without reoperation for 13, 24, and 123 months areu2028 95.56 ± 3.04%, 90.66 ± 4.40%, and 60.32 ± 12.63%, respectively. Mean survival for reoperated patients is 99 ± 14 months (95% confidence interval 72–127 months). Conclusions: Reoperations can be done with low morbidity and mortality. Patients should be kept under close follow‐up using imaging techniques infinitely.

Surgery for Chronic Total Occlusion of the Left Main Coronary Artery— Myocardial Preservation

Abstractu2003 We report seven patients with chronic total occlusion of the left main coronary artery that were operated in our institution and discuss the myocardial preservation options in these patients. In addition to total occlusion of the left main coronary artery, three patients also had severe lesions of right coronary artery. Prior myocardial infarction history and significantly depressed left ventricle functions were detected in all three patients with right coronary artery lesions. Five patients were operated on cardiopulmonary bypass while two patients were operated off pump. All patients received alternating antegrade/retrograde cardioplegia for myocardial preservation. In patients with simultaneous right coronary artery disease we first established the origin of the collaterals to the left coronary system. For patients with collaterals arising from the right coronary artery segment distal to the right coronary artery lesion, the antegrade component was administered through the saphenous vein graft bypassed to a distal part of right coronary artery segment. Thus we have achieved a more effective distribution of the antegrade cardioplegia. In off‐pump‐operated patients the left coronary system was revascularized before the right coronary system. Postoperative low cardiac output syndrome occurred in only one patient who was operated off pump. There was no operative and early mortality. Mean follow‐up was 32 ± 21.42 (range, 4 to 60) months. Alternating antegrade/retrograde cardioplegia was used with acceptable results in patients with total occlusion of the left main coronary artery. In patients with simultaneous RCA lesion we recommend regulation of the antegrade component based on the origin of collaterals that supplies the left coronary system. In off‐pump‐operated patients we suggest avoiding of clamping of right coronary artery at the beginning of the operation while it still supplies all the coronary circulation.

Aspartate and Glutamate‐Enriched Cardioplegia in Left Ventricular Dysfunction

Abstractu2003 Background: The effects of exogenous L‐aspartate and L‐glutamate‐enriched cardioplegia on postoperative left ventricular functions after coronary artery bypass surgery in patients with moderate left ventricular dysfunction (left ventricular ejection fraction [LVEF]= 30–40%) were studied. Methods: In this prospective randomized study, 22 patients with moderate left ventricular dysfunction (mean LVEF = 37.27%± 3.43%), who underwent elective coronary artery bypass surgery, were examined. Isothermic substrate‐enriched [L‐aspartate and L‐glutamate (13 mmol/L)] blood cardioplegia was used in 11 patients (Group AG), and cardioplegia including only potassium and sodium bicarbonate was used in 11 patients (Group C). All hemodynamic parameters for left and right heart were studied in both groups. Total perfusion time was 126.63 ± 44.91 minutes versus 114.81 ± 43.66 minutes (p = 0.54). The aortic cross‐clamp time was 77.09 ± 28.02 minutes versus 67.81 ± 22.77 minutes (p = 0.4), respectively. The amount of cardioplegic solutions were 7218.2 ± 3043.6 mL versus 5454.5 ± 3048.1 mL (p = 0.167). Mean number of distal anastomosis were 3 ± 0.89 versus 2.9 ± 0.7 (p = 0.793). Results: There was no difference between both groups in intra‐ and postoperative periods. In coronary sinus blood gas measures, myocardial acidosis caused by the aortic cross‐clamp was found to be more severe in the Group C, but delta pH (0.12 ± 0.14 vs. 0.092 ± 0.058; p = 0.613) and delta lactate (1.39 ± 1.03 vs. 1.62 ± 0.85; p = 0.579) were similar in both groups. Free oxygen radical production caused by aortic cross‐clamp was significant in the Group C. Not all myocardial enzymes, but Troponin‐T levels were found higher in control group than the study group (0.6 ± 0.36 vs. 0.36 ± 0.25; p = 0.1). Conclusions: Although L‐aspartate and L‐glutamate favor myocardial metabolic functions, they do not have any affect on myocardial functional recovery in patients with moderate left ventricular dysfunction.

Reversed-J Inferior Versus Full Median Sternotomy: Which Is Better for Awake Coronary Bypass Surgery

Abstractu2003 Background: The aim of this study was to ascertain whether the approach with a less invasive reversed‐J inferior sternotomy could improve intraoperative patient compliance and postoperative recovery than the standard median sternotomy. Methods: Seventeen patients underwent elective single coronary artery bypass graft operation under high thoracic epidural anesthesia without endotracheal intubation. The reversed‐J sternotomy was performed in 10 patients (Group A) and full sternotomy in 7 patients (Group B). The technical and surgical difficulties, pulmonary functions (by spirometric tests) and hospital stay were assessed. Results: Through the reversed‐J sternotomy coronary revascularization was accomplished without any additional technical difficulties and with a good exposure of both the left anterior descending artery and the left internal thoracic artery. No conversion to standard sternotomy and no intubation were observed. Additional doses of local anesthetic at jugular notch was not required in Group A. Pleura was opened more in Group B (57% vs. 20%; p = 0.14). Oxygen saturation was better in Group A during the surgical procedure (98.8 ± 0.7% vs. 97.1 ± 2.1%; p = 0.033), however, intraoperative PaCO2 was similar in both the groups. The patients in Group A were discharged from the hospital earlier (3.2 ± 1.5 vs. 7.3 ± 3.5 days; p = 0.004). Conclusions: Less invasive approach to coronary artery bypass graft operations is possible through combination of the high thoracic epidural anesthesia and a reversed‐J sternotomy. This technique is less traumatic for patient and provides practical better oxygenation and shorter hospital stay.