Ibrahim Yekeler

Impact of day versus night as intervention time on the outcomes of primary angioplasty for acute myocardial infarction

Background: Conflicting datas exist regarding the outcomes of primary percutaneous coronary intervention (PCI) for ST‐segment elevation myocardial infarction (STEMI) when the intervention is performed during night hours. Methods and Results: 2,644 consecutive patients with STEMI (mean age 56.7 ± 11.9, years, 2,188 male) undergoing primary PCI between October 2003 and March 2008 were retrospectively enrolled into this study (single high‐volume center: >3,000 PCIs/year). Day time was defined according to intervention between 08:00 am and 06:00 pm and night as intervention time between 06:00 pm and 08:00 am. 1,141 patients (43.2%) were treated during the day and 1,503 (56.8%) at night. The baseline characteristics of both groups were similar except for more frequent hypertension (42.6 vs. 36.5%; P = 0.002), women (19.7 vs. 15.4%; P = 0.003), and old (≥75y) patients (9.6 vs. 7.4; P = 0.046) in the day time group. Compared with those treated during night time, day time patients had longer angina‐reperfusion times (mean, 205 vs. 188 minutes, P = 0.016). Door‐to‐balloon times were similar (P = 0.87), and less than 90 minutes in both groups. There were no differences concerning clinical events and PCI success between the two groups. Hospital mortality was 6.1% during the day and 5.2% during the night (OR 0.98, 95% CI 0.7–1.36; P = 0.89). The median follow‐up time was 21 months. The Kaplan‐Meier survival plot for long‐term cardiovascular death was not different for both groups (P = 0.78). In‐hospital and long‐term cardiovascular mortality was also similar in shock and nonshock subgroups. Conclusions: Primary PCI can be performed safely during the night at a high‐volume PCI center with suitable and effective organization of cardiology department and catheterisation laboratory with 24 hours per day, 7 days per week onsite staffing.

Mortality predictors in ST-elevated myocardial infarction patients undergoing coronary artery bypass grafting.

The use of coronary artery bypass grafting (CABG) in primary treatment of acute myocardial infarction is still debated. We evaluated the predictors of mortality in patients undergoing primary CABG for ST-elevated myocardial infarction (STEMI). Between January 2003 and January 2008, all patients referred to our institution with STEMI who did not qualify for primary angioplasty and required CABG were included in this study. Survivors and nonsurvivors were compared retrospectively in terms of demo-graphics, preoperative, intraoperative, and postoperative characteristics. Preoperatively confirmed cases of STEMI (n = 150) were included in the analysis. There were 114 survivors and 36 nonsurvivors. In-hospital mortality rate was 22%. In Cox regression analysis age, cardiogenic shock (Killip ≥3), preoperative cardiac troponin levels, preoperative use of intra-aortic balloon counterpulsation (IABP), previous myocardial infarction, and percutaneous coronary intervention were independent predictors of in-hospital mortality. After multivariate analysis, factors predicting in-hospital mortality were age, preoperative cardiac troponin levels, and preoperative IABP. Age, preoperative cardiac troponin levels, and preoperative IABP use were predictive factors of in-hospital mortality in patients undergoing primary CABG for STEMI.

Ruptured and Non-ruptured Sinus of Valsalva Aneurysms: Five Case Studies

Between 1987 and 2000, we observed retrospectively a series of five cases of surgically treated sinus of Valsalva aneurysms (SVAs) at the Department of Cardiovascular Surgery, Atatürk University, Erzurum, Turkey. The mean age of the five patients was 32.6 years (range, 18–48 years). Three were male and two were female. Aneurysms originated from the right coronary sinus in four patients, and from the non-coronary sinus in one. Three aneurysms fistulized to the right ventricle, one to the right atrium and the last, originating from the right coronary sinus, was non-ruptured. Two aortic insufficiencies, two ventricular septal defects, one patent ductus arteriosus and one left ventricular outlet obstruction were found as concomitant lesions. All cases were symptomatic. Ruptured SVAs were repaired by double approach involving both the chamber and aortic root. There was no late mortality either in the hospital or during the follow-up period (mean 40.4 months, range 13–66 months). No patient required re-operation.

Preoperative risk factors for in-hospital mortality and validity of the Glasgow aneurysm score and Hardman index in patients with ruptured abdominal aortic aneurysm:

The aim of this study is to evaluate the validity of the Glasgow aneurysm score (GAS) and Hardman index in patients operated on because of ruptured abdominal aortic aneurysm (rAAA), and determining preoperative risk factors that affect in-hospital mortality. One hundred one patients operated on to repair a rAAA within the last 10 years were included. The GAS and Hardman index were calculated for each patient separately. The relation between in-hospital mortality and the Hardman index and GAS was analyzed by means of the receiver-operator characteristic (ROC) curve. Univariate and multivariate methods of analyses were used to determine preoperative risk factors. Average age was 69 ± 8, and in-hospital mortality rate was 51.5%. Analysis of the ROC curve showed that the Hardman index had an area under the curve (AUC) = 0.71 (95% confidence interval [CI], 0.593–0.800, P = 0.0002) for predicting in-hospital mortality. The GAS had an AUC = 0.77 (95% CI, 0.680–0.851, P < 0.0001). The results of multivariate analysis revealed the presence of the following preoperative risk factors: age more than 63 years (odds ratio [OR], 4.4; 95% CI, 1.17–16.49, P = 0.028); loss of consciousness (OR, 9.33; 95% CI, 1.94–44.86, P = 0.005); creatinine higher than 1.7 mg/dL (OR, 5.52; 95% CI, 1.92–15.85, P = 0.001); and pH lower than 7.31 (OR, 3.77; 95% CI, 1.18–11.99, P = 0.024). In conclusion, the Hardman index and GAS have a significant correlation with in-hospital mortality rates. Nevertheless, a high score does not necessarily correspond with a definite mortality. This is why scoring systems could not be considered as the sole criterion for choosing patients for this study. Clinical experience was still the leading factor in deciding against or in favor of surgery.

Is the aortic valve pathology type different for early and late mortality in concomitant aortic valve replacement and coronary artery bypass surgery

We assessed the effects of aortic valve pathology type on the long-term outcomes of patients who underwent concomitant aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) surgery. We retrospectively reviewed 150 patients who underwent AVR-CABG at our institution between January 1997 and December 2006. We divided patients into aortic stenosis (AS), aortic regurgitation (AR), and mixed-type groups consisting of 98 (65.3%), 20 (13.3%) and 32 (21.3%) patients, respectively. The AS group had more female patients, a higher mean angina class, older mean patient age, increased history of previous myocardial infarction (MI), and smaller valve size compared to other groups. No significant differences were observed among groups in the operative mortality for five or ten-year survival rates. Significant early mortality risk factors included cross-clamp and cardiopulmonary bypass (CBP) time, number of blood transfusion units, chronic obstructive pulmonary disease (COPD), intra-aortic balloon pump (IABP), inotropic drugs, and pacemaker use. Significant late mortality risk factors included intensive care unit (ICU) stay, IABP, stroke, and dialysis. The aortic valve pathology type in patients undergoing concomitant AVR-CABG does not adversely affect survival.

Time and risk analysis for acute type A aortic dissection surgery performed by hypothermic circulatory arrest, cerebral perfusion, and open distal aortic anastomosis.

BACKGROUND Hypothermic total circulatory arrest, retrograde or antegrade cerebral perfusion, and open distal anastomosis are important stages of surgical management and cerebral protection for acute type A dissections. Among the factors that influence survival are the transfer time to hospital from the onset of symptoms, in-hospital transfer time to operation, organ malperfusion, preoperative risk factors, and intraoperative variables. The aim of this study was to analyze time and risk factors during surgical management. METHODS Between September 1996 and March 2002, a total of 26 patients with acute type A aortic dissection were operated. Sixteen patients (61.5%) were male and mean age was 49 ( 13.1 years (range: 26-68). The diagnosis was based on clinical examination, telecardiography, transthoracic echocardiography, computerized tomography, and angiography. Hypothermic total circulatory arrest, retrograde or antegrade cerebral perfusion and open distal anastomosis were used during the procedures. Operative techniques were as follows: supracoronary ascending aortic replacement (17 patients), aortic root and ascending aortic replacement with flanged composite grafting technique (5 patients), replacement of ascending aorta and hemiarcus (1 patient), aortic root and ascending aortic replacement with modified Bentall technique (1 patient), replacement of ascending aorta and arcus (1 patient), and total arcus replacement with elephant trunk technique and modified Bentall procedure (1 patient). RESULTS The early postoperative mortality rate within the first 30 days was 26.9%, and the late postoperative mortality rate was 15.8%. Two patients (7.7%) developed major neurological complications during the postoperative period. Time to admission, durations of total circulatory arrest, cross-clamp, cardiopulmonary bypass, and intubation were longer, and postoperative blood loss was greater in patients who died during early postoperative period, although the differences did not reach statistical significance. Duration of total circulatory arrest was longer in patients who developed neurological dysfunction compared to patients without this complication; this difference also did not reach statistical significance. CONCLUSIONS Total circulatory arrest, cerebral perfusion, and open distal anastomosis are reliable options in the surgical management of acute type A aortic dissections. With open distal anastomosis aortic arcus can be evaluated, distal anastomosis can be performed more easily, and postoperative neurological recovery is hastened. In the present study, although statistical significance could not be reached due to limited sample size, the time to admission, durations of total circulatory arrest, cross-clamp, and cardiopulmonary bypass, and the amount of postoperative chest output seem to influence postoperative survival.

Carotid Body Tumors (Paragangliomas)

Carotid body tumors were diagnosed in 19 patients (13 females and 6 males) between 1977 and 2000. All but one were operated upon. The ages of the 18 surgically treated patients ranged from 17 to 65 years. Carotid body tumor was confirmed in 16 cases; the diagnosis was neurofibroma in 1 and tuberculosis lymphadenitis in 1. The carotid body tumors were resected without a shunt procedure. Eight patients underwent total resection, 6 had resection and saphenous vein interposition, 1 had partial resection, and 1 had carotid artery ligation with no resultant neurological deficit. One case of hypoglossal paralysis and one benign ipsilateral recurrence were detected. Contralateral recurrence was detected in 1 patient 4 years postoperatively. No mortality or malignant course was observed.

Results for Surgical Closure of Isolated Ventricular Septal Defects in Patients Under One Year of Age

This study evaluated the outcomes of patients undergoing surgical repair of isolated ventricular septal defect (VSD) in the first year of life with particular attention to age and severity of pulmonary hypertension (PH).

Randomized comparison between mild and moderate hypothermic cardiopulmonary bypass for neonatal arterial switch operation

OBJECTIVES To compare neonates receiving arterial switch operation (ASO) either with mild or moderate hypothermic cardiopulmonary bypass. METHODS Forty neonates undergoing ASO were randomized to receive either mild (Mi > 32 °C, n = 20) or moderate (Mo > 26 °C, n = 20) hypothermic cardiopulmonary bypass (CPB) between April 2007 and June 2010. All patients were diagnosed with simple transposition of the great arteries. Mean age (Mi: 8.32 ± 4.5 days, Mo: 7.54 ± 5.0 days, P = 0.21) and body weight were similar in both groups (Mi: 3.64 ± 0.91 kg, Mo: 3.73 ± 0.84 kg, P = 0.14). Follow-up was 3.1 ± 2.5 years for all patients. RESULTS Lowest perioperative rectal temperature was 33.5 ± 1.4 °C (Mi) versus 28.2 ± 2.1 °C (Mo) (P < 0.001). All patients safely weaned from CPB required lower doses of dopamine (Mi: 5.1 ± 2.4 µg/kg min, Mo: 6.5 ± 2.1 µ/kg min, P = 0.04), dobutamine (Mi: 7.2 ± 2.5 µg/kg min, Mo: 8.6 ± 2.4 µ/kg min, P = 0.04) and adrenalin (Mi: 0.02 ± 0.02 µg/kg min, Mo: 0.05 ± 0.03 µ/kg min, P = 0.03) in mild hypothermia group. Intraoperative blood transfusion (Mi: 190 ± 58 ml, Mo: 230 ± 24 ml, P = 0.03) and postoperative lactate levels (Mi: 2.7 ± 0.9 mmol/l, Mo: 3.1 ± 2.2 mmol/l, P = 0.02) were lower under mild hypothermia. Secondary chest closure was performed in 30% (Mi) versus 35% (Mo) (P = 0.65). Duration of inotropic support (Mi: 7 (4-11) days, Mo: 11 (7-15) days, P = 0.03), time to extubation (Mi: 108 (88-128) h, Mo: 128 (102-210) h, P = 0.04), lengths of intensive care unit (ICU) stay (Mi: 9 (5-14) days, Mo: 12 (10-18) days, P = 0.04) and hospital stay (Mi: 19 (10-29) days, Mo: 23 (15-37) days, P = 0.04) were significantly shorter under mild hypothermia. Two-year freedom from reoperation was 100% for both the groups. CONCLUSIONS The ASO under mild hypothermia seemed to be beneficial for pulmonary recovery, need for inotropic support and length of ICU and hospital stay. No worse early- or intermediate-term effects of mild hypothermia were found.

An approach to cultural adaptation and validation: the Intermittent Claudication Questionnaire

Abstract The objective of this study was to perform a cultural adaptation and define the validity of the Turkish version of the Intermittent Claudication Questionnaire (ICQ) in order to provide a practical instrument for the evaluation of the impact of intermittent claudication (IC) on patients’ quality of life and response to therapy. A standard ‘forward–backward’ translation method was used to translate the questionnaire into Turkish. Reliability was assessed by internal consistency of the questionnaire reporting Cronbach’s α coefficient, test–retest reliability that was assessed with the intraclass correlation between instrument scores over time and with the Spearman–Brown coefficient as a variant of split-half reliability. Validity was examined by correlation of the ICQ with the scores of the SF-36 and its eight domains. Eighty-four patients (mean age, 60.7 ± 7.3 years; male, 57%) were given the ICQ and a final completion rate of 98.8% (83 patients) was reached. The mean total ICQ score was 39.1 ± 21.8 (SD) (0–100) for the first application of the questionnaire. Thirty patients out of the eligible 83 completed the questionnaire at two time points with a 1-day interval. For the retest, the total ICQ score was 40.6 ± 26.1 (4.7–97.2). The total SF-36 score of all the study patients was 33.8 ± 20.7 (3.0–81.0). Cronbach’s α was 0.95; the Spearman–Brown coefficient was 0.92; and the intraclass correlation coefficient for the two measurements was 0.91. For the total score and for the scores of domains except the emotional role domain, the correlations were high and all the correlations were statistically significant. In conclusion, the Turkish version of the ICQ, which is a disease-specific, self-administered, and practical instrument, is reliable and valid. We recommend its use to assess the effect of IC on the quality of life of patients in clinical trials and in daily clinical practice.