Kerem Oral

Angiographic evaluation of graft patency in robotic‐assisted coronary artery bypass surgery: 8 year follow‐up

Robotic telemanipulation systems have emerged as facilitating tools that enhance minimally invasive cardiac surgery.The purpose of this study was to evaluate graft patency by a combination of invasive and non‐invasive coronary angiography methods in robotic‐assisted coronary artery surgery(CABG) for optimal quality control.

Left atrial myxoma with neovascularization presenting as a sick sinus syndrome.

Myxoma is benign tumor of the heart. It is mostly located in the left atrium and revascularized by the left and right coronary artery in 30% to 40% of cases. Symptoms of these neovascularized cardiac myxomas are typically quite variable, from obstruction of mitral valve to coronary embolism resulting in acute myocardial infarction. In this case, left atrial myxoma that is revascularized by nodal branches of the right coronary artery presented as a sick sinus syndrome, which is rare in literature.

Rapid Detection of Acute Kidney Injury by Urinary Neutrophil Gelatinase-Associated Lipocalin in Patients Undergoing Cardiopulmonary Bypass.

OBJECTIVE Acute kidney injury (AKI) is common following cardiopulmonary bypass (CPB). The aim of this study is to determine the accuracy of urinary neutrophil gelatinase-associated lipocalin (NGAL) levels following cardiac surgery to establish the severity of renal impairment as compared to serum creatinine levels. METHODS A total number of 28 patients undergoing elective cardiopulmonary bypass were included. Diagnostic criteria of AKI was established in case of a percentage increase in serum creatinine concentration of >50%. Serum creatinine levels were recorded in the preoperative period before induction and in the postoperative period at 24, 48, and 72 hours. Urinary NGAL measurement was performed before induction and in the 4(th) postoperative hour. The duration of CPB surgery, hospital stay, and cross-clamp time were recorded. RESULTS Based on AKI criteria, subjects were grouped as AKI (n=11) and no AKI (n=19). Postoperative urinary NGAL levels were significantly higher in the group with AKI (11.8 ng mL(-1) vs. 104.0 ng mL(-1), p=0.003). In the AKI group, CPB time bypass (111.9 min vs. 82.7 min) and cross-clamp time (76.9 min vs. 59.1 min) were significantly higher. A cut-off of 25.5 ng mL(-1) yielded a sensitivity of 81.82% and a specificity of 94.12% at the postoperative 4(th) hour with an AUC of 0.947 for predication of AKI. CONCLUSION Urine NGAL rose significantly much earlier as compared to serum creatinine levels in the early postoperative period. Although larger case series are needed, we are of the opinion that urinary NGAL measurements may be used as an early clinical marker of AKI following CPB.

Pain and the Quality of Life Following Robotic Assisted Minimally Invasive Surgery

OBJECTIVE Minimally invasive bypass grafting is a promising surgical treatment in proximal LAD stenosis procedures. The main goal of this study was to make comparisons between robotically assisted minimally invasive coronary bypass surgery and conventional surgery in isolated proximal LAD lesions in terms of pain and quality of life improvement. METHODS The study contains patients with proximal LAD lesions who were treated with robotically assisted minimally invasive coronary artery bypass surgery and conventional bypass surgery between June 2005 and November 2012. Fifty patients treated with coronary bypass with cardiopulmonary bypass and complete sternotomy were categorized as Group 1. Fifty patients who applied for robotically assisted minimally invasive bypass surgery were categorized as Group 2. The evaluations of pain and quality of life were done according to the Verbal Rating Scale (VRS) and SF-36 health survey questionnaire, respectively. RESULTS The conventional bypass group and robotic group had 4.8 ± 1.9 years and 4.3 ± 1.6 years mean follow-up time, respectively. The robotic bypass group had a significantly shorter ICU stay and hospital stay than the conventional bypass group (P < .05). The pain score was higher in the robotic bypass group on the 1st postoperative day (P < .05), but the score on the 4th postoperative day was higher in the conventional bypass group (P < .05). In terms of domains of the SF-36 questionnaire, patient scores were significantly higher in patients who were operated with robotically assisted minimally invasive direct coronary artery bypass (MIDCAB) procedure than in patients who were operated with conventional bypass technique. CONCLUSION Patients operated with robotically assisted MIDCAB procedure had results with lesser pain, shorter ICU stay, and shorter hospital stay than the other group in isolated proximal LAD stenosis. The same group also had better quality of life results according to the SF-36 questionnaire results.

Hybrid vascular surgery approaches for multilevel arterial occlusive disease.

BACKGROUND The incidence of multilevel vascular occlusive disease is increased with patient age. Multilevel arterial occlusive disease cases are some of the hardest in the vascular surgical realm because of the comorbidities. In these high-risk patients inflow constrictions may limit the success of distal bypasses. At the same time the constrictions in the outflow may necessitate long bypass circuits that have less long-term patency rates. METHODS Our study included 38 patients with multilevel arterial occlusive disease to whom hybrid vascular approaches were applied between January 2005 and December 2011 in Şişli Florence Nightingale Hospital. The patient group had a mean age of 68.1 (48-98) and included 29 male (89%) and 9 female (11%) patients. Complaints were claudication under 100 meters of walking in 19 patients (50%), resting pain in 14 patients (36%), and disturbed tissue integrity in 5 patients (14%). Mean in-hospital stay was calculated to be 6.4 days (4-15). In one patient (2.6%), a second procedure was necessary due to graft thrombosis and this case resulted in amputation under the level of the knee. Minor toe amputations in a second session were applied to 5 patients (14%) with symptoms of foot sores. Wound infections occurred in two patients (5%) and were treated with antibiotherapy and wound care. RESULTS At the end of the follow-up time, extremity survival was found to be 94.1%. CONCLUSIONS In the treatment of multilevel peripheral arterial occlusive disease, a hybrid approach is a treatment option which is less invasive and sufficient.

The Comparison between Minimally Invasive Coronary Bypass Grafting Surgery and Conventional Bypass Grafting Surgery in Proximal LAD Lesion.

BACKGROUND Minimally invasive bypass grafting surgery has entered the clincal routine in several centers around the world, with an increasing popularity in the last decade. In our study, we aimed to make a comparison between minimally invasive coronary artery bypass grafting surgery and conventional bypass grafting surgery in isolated proximal left anterior descending artery (LAD) lesions. METHODS Between January 2004 and December 2011, patients with proximal LAD lesions, who were treated with robotically assisted minimally invasive coronary artery bypass surgery and conventional bypass surgery, were included in the study. In Group 1, coronary bypass with cardiopulmonary bypass and complete sternotomy were applied to 35 patients and in Group 2, robotically assisted minimally invasive bypass surgery was applied to 35 patients. The demographic, preoperative, perioperative, and postoperative data were collected retrospectively. RESULTS The mean follow-up time of the conventional bypass group was 5.7 ± 1.7 years, whereas this ratio was 7.3 ± 1.3 in the robotic group. There was no postoperative transient ischemic attack (TIA), wound infection, mortality, or need for intra-aortic balloon pump (IABP) in any of the patients. In the conventional bypass group, blood transfusion and ventilation time were significantly higher (P < .05) than in the robotic group. The intensive care unit (ICU) stay and hospital stay were remarkably shorter in the robotic group (P < .01). The postoperative pneumonia rate was significantly higher (20%) in the conventional bypass group (P < .01). Postoperative day 1 pain score was higher in the robotic group (P < .05), however, postoperative day 3 pain score in the conventional bypass group was higher (P < .05). Graft patency rate was 88.6% in the conventional bypass group whereas this ratio was 91.4% in the robotic bypass group, which was not clinically significant (P > .05). CONCLUSIONS In isolated proximal LAD stenosis, robotic assisted minimally invasive coronary artery bypass grafting surgery requires less blood products, is associated with shorter ICU and hospital stay, and lesser pain in the early postoperative period in contrast to conventional surgery. The result of our studies, which showed similarities to the past studies, lead us to recognize the importance of minimally invasive interventions and the need to perform them more frequently in the future.

Left ventricular mass regression after aortic valve replacement

OBJECTIVE Our objective was to evaluate the degree of change in left ventricular mass index (LVMI) regression after aortic valve replacement (AVR) using three different valves. METHODS Group 1 (n=17) included patients with bioprosthesis (Medtronic Hancock 2), Group 2 (n=21) included patients with mono-leaflet mechanical valve (Medtronic Hall), and Group 3 (n=17) included patients with bi-leaflet mechanical valve (St Jude). The mean ages of Group 1, 2 and 3 patients were 70.8±9.1, 61.6±13.7 and 56.2±18.3 years, respectively. In this observational study, patients were followed-up after surgery and left ventricular wall thickness and valvular functions were evaluated with echocardiography. The findings were compared with preoperative values. Statistical analyses were performed using one-way variance analysis (ANOVA), Kruskal -Wallis, and Chi-square tests. RESULTS Statistically significant difference was observed among the three groups with respect to age (p=0.015). LVMI regressed in all groups; Group 1 from 232.74±53.36 g/m² (preoperative) to 174.64±46.33 g/m² (postoperative) (p=0.0001), Group 2-from 198.49±40.53 g/m2 to 167.04±33.9 g/m² (p=0.0001), and Group 3-228.77±47.87 g/m² to 185.44±37.76 g/m² (p=0.0001). No statistically significant difference was observed among the groups with respect to LVMI regression (p=0.054, p=0.363). CONCLUSION Mid-term results of AVR with three different aortic valve prosthesis revealed that all groups showed a similar regression of left ventricular mass. However, we advocate that long-term results of an increased number of patients should be evaluated for assessment in depth.