Mehmet Cakici

Coexistence of left-sided inferior vena cava, deep vein thrombosis of the upper and lower extremities and prothrombotic polymorphisms in a young patient: a case report.

A literature review suggests an interaction between an anomaly of the inferior vena cava and thrombophilia in the pathogenesis of deep vein thrombosis. Genetic thrombotic abnormalities have been found in some of the subjects having venous thromboembolic diseases. We report a case of a young man presenting with venous thrombosis of the upper and lower extremities, left-sided vena cava inferior and with combination of heterozygosity of the mutation of the genes Methylenetetrahydrofolate reductase 677 and Factor V 1691.

Sutureless aortic valve replacement with concomitant valvular surgery

Objectives: Sutureless aortic valve replacement (SU‐AVR) is an alternative technique to standard aortic valve replacement. We evaluated our experience with the Perceval SU‐AVR with concomitant mitral valve surgery, with or without tricuspid valve surgery, and aimed to discuss the technical considerations. Methods: From January 2013 through June 2016, 30 patients with concomitant severe mitral valve disease, with or without tricuspid valve disease, underwent SU‐AVR with the Perceval prosthesis in a single center. Results: The mean age was 73.0 ± 6.6 years, ranging from 63 to 86 years, and 60% (n = 18) were male. Mean logistic EuroScore of the study cohort was 9.8 ± 4.6. Concomitant procedures consisted of mitral valve repair (n = 8, 26.6%), mitral valve replacement (n = 22, 73.3%), tricuspid valve repair (n = 18, 60%), tricuspid valve replacement (n = 2, 6.6%), and cryoablation for atrial fibrillation (n = 21, 70%). Median prosthesis size was 25 mm (large size). At 1 year, there were 2 deaths from noncardiac causes. One patient (3.3%) had third‐degree atrioventricular block requiring permanent pacemaker implantation. Three patients (10%) had intraoperative supra‐annular malpositioning of the aortic prosthesis, which was safely removed and reimplanted in all cases. Mean follow‐up was 18 ± 4.5 for months (maximum 3 years). During the postoperative period, sinus rhythm restoration rate in patients who underwent the cryo‐maze procedure was 76.1% (n = 16) at discharge. There was no structural valve deterioration or migration of the prosthesis at follow‐up. Conclusions: Perceval SU‐AVR is a technically feasible and safe procedure in patients with severe aortic stenosis with good results even in the presence of multivalvular disease and atrial fibrillation surgery.

Controlled flow diversion in hybrid venoarterial–venous extracorporeal membrane oxygenation

OBJECTIVES Patients on venoarterial or venovenous extracorporeal membrane oxygenation (ECMO) support may require venoarterial-venous (VAV-ECMO) configuration during follow-up. We report 12 cases of VAV-ECMO with significant outflow steal. METHODS Between October 2014 and November 2016, a total of 97 patients (56.6 ± 12.0 years; 59 men/38 women; body surface area 1.84 ± 0.36 m2) were supported with venoarterial ECMO (n = 85) or venovenous ECMO (n = 12). Among the 97 patients, 12 patients (age 61.5 ± 3.5 years; 8 men/4 women; body surface area 1.8 ± 0.8 m2) required hybrid use of VAV-ECMO. Control and monitoring of flow ratios in supplying cannulae using flow sensors were performed, and occluder devices were used according to patient requirements to achieve optimum haemodynamics and oxygenation. RESULTS Among the 85 venoarterial ECMO-supported patients, Harlequin syndrome was detected in 9 cases (10.6%) who required switching to VAV-ECMO. Among the 12 patients, 3 (25%) patients required VAV-ECMO while on venovenous ECMO support as a result of initial respiratory failure subsequently developed cardiac decompensation. Mean duration of VAV-ECMO support was 6.4 ± 1.8 days. Overall, on VAV-ECMO support, 70.0 ± 4.6% of blood flow was detected within the supplying right internal jugular vein cannula as a result of lower afterload in venous system. We partially occluded the internal jugular vein cannula and directed flow to the common femoral artery. After adjustment, 34.3 ± 7.4% flow was directed to internal jugular vein and 65.6 ± 7.4% to common femoral artery. CONCLUSIONS Non-invasive monitoring of flow rates within the supplying cannulae of VAV-ECMO and the use of partial occlusion for venous-supplying cannula enable individualized patient management and effective weaning from VAV-ECMO.

A retrospective cohort analysis of percutaneous versus side-graft perfusion techniques for veno-arterial extracorporeal membrane oxygenation in patients with refractory cardiogenic shock

Objectives: This study was designed to compare vascular complications and the outcomes of ultrasound (US)-guided percutaneous cannulation with distal perfusion catheter (PC-DP) and arterial side-graft perfusion (SGP) techniques in patients who require veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support for refractory cardiogenic shock (RCS). Methods: We conducted a retrospective, observational cohort study of consequtive patients with RCS treated with VA-ECMO at a single transplant center from March 2010 until August 2015. Overall, 148 patients underwent VA-ECMO for RCS (99 men, aged 56.6 ± 12.0 years; BSA, 1.85 ± 0.19). Patients were categorized based on VA-ECMO perfusion technique into PC-DP via femoral artery and SGP via axillary/femoral artery groups. Results: The median duration of VA-ECMO support was 5 days (range, 8 hours–80 days). Hospital mortality (PC-DP group, 54.7%; SGP group, 64.4%; p=0.23) and overall ECMO survival (PC-DP group, 36.9%; SGP group, 32.2%; p=0.47) was similar between the groups. There were no significant between-group differences in the rate of acute limb ischemia (PC-DP group, 4/75, 5.3%; SGP group, 2/73, 2.7%; p=0.68). However, the rate of surgical/cannulation site bleeding (PC-DP, 9/75 (12%) vs SGP, 18/73 (24.7%), p=0.05) and hyperperfusion syndrome (PC-DP, 2/75 (2.7%) vs SGP, 22/73 (30.1%),p=0.001) were higher in the SGP group than in the PC-DP group. Conclusions: We observed no significant difference in major vascular complications or survival between patients who underwent the PC-DP technique and those who underwent arterial SGP.

Promising utilization areas of therapeutic plasmapheresis in cardiovascular surgery practice

OBJECTIVE Apheresis is performed for treatment of numerous diseases by removing auto-antibodies, antigen-antibody complexes, allo-antibodies, paraproteins, non-Ig proteins, toxins, exogenous poisons. In current study, we present our experience of using therapeutic plasma exchange (TPE) in patients with different types of clinical scenarios. METHODS Between January 2013 and May 2016, we retrospectively presented the results of 64 patients in whom postoperative TPE was performed in ICU setting after cardiac surgery. Patients were grouped into four as; 1-sepsis (n = 26), 2-hepatorenal syndrome(n = 24), 3-antibody mediated rejection(AMR) following heart transplantation(n = 4) and 4-right heart failure(RHF) after left ventricular asist device(LVAD)(n = 10). Hemodynamic parameters were monitored constantly, pre- and post-procedure peripheral blood tests including renal and liver functions and daily complete blood count (CBC), sedimentation, C-reactive protein and procalcitonin (ng/ml) levels were studied. RESULTS The mean age was 61 ± 17.67 years old and 56.25% (n = 36) were male. Mean Pre TPE left ventricular ejection fraction (LVEF) (%), central venous pressure (CVP)(mmHg) pulmonary capillary wedge pressure (PCWP)(mmHg) and pulmonary arterial pressure (PAP)(mmHg) were measured as 41.8 ± 8.1, 15.5 ± 4.4, 17.3 ± 3.24 and 39.9 ± 5.4, respectively. Procalcitonin (ng/ml) level of patients undergoing TPE due to sepsis was significantly reduced from 873 ± 401 ng/ml to 248 ± 132 ng/ml. Seventeen (26.5%) patients died in hospital during treatment, mean length of intensive care unit (ICU) stay(days) was 13.2 ± 5.1. CONCLUSION This study shows that TEP is a safe and feasible treatment modality in patients with different types of complications after cardiac surgery and hopefully this study will lead to new utilization areas.

Sutureless Valve Replacement Through a Right Anterior Mini-thoracotomy In Elderly Patients With Stenotic Bicuspid Aortic Valve

Several indications for sutureless aortic valve replacement (SU-AVR) have been a matter of debate. We evaluated our experience with Perceval-S (LivaNova group, Saluggia, Italy) SU-AVR in patients with severe aortic stenosis (AS) involving bicuspid aortic valve (BAV), even though presence of BAV is still considered to be a contraindication for sutureless valves. From January 2013 through March 2018, 13 patients with severe AS involving BAV underwent SU-AVR with the Perceval-S (LivaNova group, Saluggia, Italy) prosthesis in a single center. Preoperative evaluation included coronary catheterization and multisliced computerized tomography was performed in all patients. Three-dimensional transthoracic echocardiography was used to evaluate for obtaining the anatomy and phenotype of BAV. Minimally invasive approach through right anterior thoracotomy from third intercostal space was performed for all patients. The mean age was 72.8 ± 2.26 years ranging from 70 to 77, and 53.8% (n = 7) were male. The mean aortic valve gradient decreased from 46.4 ± 13.8 to 13.6 ± 4.4 mmHg postoperatively. The mean aortic valve area increased from 0.69 ± 0.22 to 1.81 ± 0.38 cm2. There was no in-hospital mortality. One patient (7.6%) had third-degree atrioventricular block requiring permanent pacemaker implantation. Mean follow-up was 15.1 ± 6.3 months (maximum 2 years). No major paravalvular leakage or valve migration occurred postoperatively. This study shows that SU-AVR is a technically feasible and safe procedure in patients with severe AS and BAV with acceptable good surgical outcomes. Presence of BAV in AS should not be considered a contraindication to Perceval-S prosthesis (LivaNova group, Saluggia, Italy).

Comparison of heat induced damage at the saphenofemoral junction after ablation with 1,470 nm laser or radiofrequency

BACKGROUND The aim of this study was to evaluate the heat induced damage at the saphenofemoral junction level according to histopathological changes after radiofrequency or 1,470 nm radial tip laser ablation. PATIENTS AND METHODS Varicose vein segments of 6-10 mm in diameter were exposed to radiofrequency (Closure Fast catheter, 7 cm heat segment, one cycle, 15 seconds, 10 Watt, 120 °C) or laser ablation (1,470 nm radial tip, continuous wave, vein diameter: 6 cm/8 cm/10 cm-power: 10 Watt-pullback speed: 2.2 mm/s, 1.7 mm/s, 1.3 mm/s-LEED: 45J/cm, 60J/cm, 75J/cm-EFE 25J/cm2, respectively). Approximate 2 cm segments of the vein were left untreated, then histopathological examinations of the untouched segments (5 slices: level 1 - furthest segment, level 2 - nearest segment) for heat induced damage were performed. A total damage scoring system was established, including the presence of endothelial swelling, intimal thickening, cellular vacuolisation in the muscle layer, oedema in the tunica media, and extent of necrosis. RESULTS At level 1, the furthest segment of the specimen, there was no significant difference between the laser and control group, while the total damage score of the radiofrequency group was significantly higher than the control group (p < 0.01). Radiofrequency group had higher total damage score compared to the laser group at level 1 (p < 0.01), 2 (p < 0.01), and 5 (p < 0.01); while no significant difference was observed at level 3 (p = 0.46) and 4 (p = 0.13). CONCLUSIONS Significant heat induced damage may be seen even if the 2 cm segment of the vessel is left unablated. Radiofrequency ablation seems to cause more histological damage than laser ablation in this ex vivo study. Further in vivo studies are necessary, in order to validate these findings.

Clinical Results of Cardiac Surgery in Patients with Chronic Hepatitis C and Their Role in Risk Models: A Case-Control Study

Abstract Background To evaluate the results of patients with chronic hepatitis C virus (HCV) following cardiac surgery in the TurcoSCORE (TrS) database. Methods Sixty patients with HCV who underwent cardiac surgery between 2005 and 2016 in our clinic out of a total 8,018 patients from the TrS database were included in the study. The perioperative morbidity and mortality rates in these patients were compared with a matched cohort. Results The mean follow‐up time was 96.6 ± 12.3 months. Hospital mortality rates (HCV group 5% vs. control group 1.7%, p = 0.61) were similar between the groups. No significant difference was found in the duration of cardiopulmonary bypass (HCV 79.1 ± 12.3 vs. control 82.6 ± 11.8, p = 0.88) and cross clamps (HCV 33.4 ± 6.9 vs control 33.8 ± 7.2 p = 0.76) between the two groups. The rate of patients who were revised due to postoperative hemorrhage was significantly higher in the HCV arm compared with the matched cohort (HCV 13.3% vs. control 1.7%, p < 0.05). Although the measured prothrombin time (PT) and international normalized ratio (INR) in the postoperative 24th hour were in normal ranges in both arms, they were significantly higher in the HCV arm (HCV 11.2 ± 1.2 vs. control 10.5 ± 0.8, p < 0.05; HCV 0.99 ± 0.06, vs. control 0.92 ± 0.03, p < 0.0001). Conclusion The presence of HCV can be an important prognostic factor for morbidity in patients undergoing cardiac surgery. It can also play an important role in the risk models generated for cardiac surgery.

Azygos Continuation of the Inferior Vena Cava Without Any Congenital Anomaly Associated with Chronic Venous Inssuffificiency: Original Image

17-year old man admitted to our hospital for the complaints of itching and pain in his lower extremity. He had presented to another hospital with leg edema and restless before. Following the physical examination and doppler ultrasonography examination in the outpatient clinic, the physician adviced to ablate great saphenous vein as a primary intervention. The parents of the patient did not give approval to the suggested treatment, then they admitted to our hospital. Physical examination revealed the signs of venous insufficiency. Laboratory findings did not present any signs of thrombosis within normal levels of D-dimer (100 ng/L), activated partial thromboplastin time of 43 seconds (therapeutic activated partial thromboplastin time range, 45-75 seconds). Venous ultrasonogram presented as venous insufficiency at the level of great saphenous vein with a reflux flow greater than 0.5 m/sec. Popliteal, femoral, and iliac venous segments were dilated and no signs of thrombosis. The venous continuity of the iliac vein segment could not screened adequately. Vena cava and the lower extremity venous system venography was scheduled for the underlying cause of the symptoms. Venogram presented dilated great saphena magna with normal patency and lumen diameter of popliteal, femoral and external iliac veins. Inferior vena cava (IVC) and bilateral common iliac veins were occluded from the origins (Figure 1). Opacity of the azygos vein was clearly seen, and lower part of the body drained into the superior vena cava (SVC) via the dilated azygos vein continuation. Well developed paravertebral veins assist the drainage of the azygoz vein.