Serpil Taş

Pulmonary endarterectomy for chronic thrombo-embolic pulmonary hypertension: an institutional experience.

OBJECTIVE Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thrombo-embolic pulmonary hypertension (CTEPH). The aim of this study was to review our initial experience since the implementation of our program. METHODS Data were collected prospectively on all patients who underwent PEA between March 2011 and March 2012. RESULTS Forty-nine patients (20 male, 29 female, mean age 47.7 years) underwent surgery. The preoperative New York Heart Association class distribution showed the majority to be in class III or IV (n = 40). Mortality rate was 14.2% (n = 7) and the morbidity rate was 26.5% (n = 13). After PEA, the durations of mechanical ventilation, intensive care stay and hospital stay before discharge were 49.7 ± 46.1 h, 6.5 ± 5.0 days and 12.9 ± 7.5 days, respectively. The systolic and mean pulmonary artery pressure (PAP) fell significantly from 87.0 ± 26.6 mmHg and 53.8 ± 14.5 before, to 41.5 ± 12.4 mmHg and 28.5 ± 10.5 after surgery (P < 0.001 and P < 0.001, respectively). Pulmonary vascular resistance (PVR) also improved significantly from 808 ± 352.0 to 308 ± 91 dyn•s•cm(-5) (P < 0.001). Univariate analysis showed that preoperative systolic PAP, tricuspid annular plane systolic excursion, right atrial volume, right atrial pressure, forced expiratory volume in 1 s, forced vital capacity, preoperative PVR, postoperative PVR, the duration of circulatory arrest and postoperative use of extracorporeal membrane oxygenation were risk factors for mortality (P < 0.05). According to multivariate analyses, only prolonged mechanical ventilation was selected as predictive risk factor for morbidity (P = 0.005). After a median follow-up of 6.1 months, two patients died due to cerebrovascular disease and one patient needed targeted pulmonary hypertension therapy. The rest of the 39 patients showed marked improvements in their clinical status. CONCLUSIONS Starting a pulmonary endarterectomy program with acceptable mortality and morbidity rates and satisfactory early-term outcomes increases awareness of the CTEPH and surgery. Preoperative factors can primarily predict postoperative outcome after PEA. Identifying the risk factors in order to achieve a good result is important for the success of a PEA program. Therefore all patients diagnosed with CTEPH should be referred for consideration of PEA in a specialized centre.

Management of Massive Pulmonary Hemorrhage Following Pulmonary Endarterectomy

Massive pulmonary hemorrhage is a potentially fatal complication of pulmonary endarterectomy. We describe a successful management in which the patients right lower lobe bronchus was occluded with a Fogarty balloon catheter while on peripheral venoarterial extracorporeal membrane oxygenation.

Neutrophil/Lymphocyte Ratio Can Predict Postoperative Mortality in Patients with Chronic Thromboembolic Pulmonary Hypertension

OBJECTIVE The aim of our study was to investigate clinical importance of neutrophil/ lymphocyte ratio in patients with Chronic thromboembolic pulmonary hypertension. METHODS 125 consecutive patients with a diagnosis of Chronic thromboembolic pulmonary hypertension were operated pulmonary thromboendarterectomy in our center between February 2011 and August 2013. 106 patients included into the study due to limitations. The patients were classified into two groups as patients discharged alive (Group 1) and those dying in the hospital (Group 2). Baseline neutrophil/lymphocyte ratio level was measured by dividing neutrophil count to lymphocyte count. RESULTS 84 patients (79%) were in Group 1, 22 patients (21%) were in Group 2. Patients with higher neutrophil/lymphocyte ratio in admission have a significantly higher mortality rate and postoperative pulmonary vascular resistance was found statistically significant variable to predict the mortality. Receiver operator characteristic (ROC) analysis revealed that using a cut-off point of 2.54, admission neutrophil/lymphocyte ratio predicts mortality. Also, correlation analysis showed a significant correlation between preoperative pulmonary vascular resistance and neutrophil/lymphocyte ratio. CONCLUSION The neutrophil/lymphocyte ratio level may be a useful and noninvasive biomarker for operative risk stratification for mortality after pulmonary thromboendarterectomy.

Surgical treatment of aortic valve endocarditis: a 26-year experience

Objective We have retrospectively analyzed the results of the operations made for aortic valve endocarditis in a single center in 26 years. Methods From June 1985 to January 2011, 174 patients were operated for aortic valve endocarditis. One hundred and thirty-eight (79.3%) patients were male and the mean age was 39.3±14.4 (9-77) years. Twenty-seven (15.5%) patients had prosthetic valve endocarditis. The mean duration of follow-up was 7.3±4.2 years (0.1-18.2) adding up to a total of 1030.8 patient/years. Results Two hundred and eighty-two procedures were performed. The most frequently performed procedure was aortic valve replacement with mechanical prosthesis (81.6%). In-hospital mortality occurred in 27 (15.5%) cases. Postoperatively, 25 (14.4%) patients had low cardiac output and 17 (9.8%) heart block. The actuarial survival rates for 10 and 15 years were 74.6±3.7% and 61.1±10.3%, respectively. In-hospital mortality was found to be associated with female gender, emergency operation, postoperative renal failure and low cardiac output. The long term mortality was significantly associated with mitral valve involvement. Male gender was found to be a significant risk factor for recurrence in the follow-up. Conclusion Surgery for aortic valve endocarditis has significant mortality. Emergency operation, female gender, postoperative renal failure and low cardiac output are significant risk factors. Risk for recurrence and need for reoperation is low.

surgical management of effusive constrictive pericarditis

Background The surgical approach for effusive constrictive pericarditis (ECP) has not been extensively studied. We present our institution’s early and long-term results of pericardiectomy in our cohort of patients with ECP. Methods Diagnosis was made primarily by echocardiography. Right heart catheterisation was performed in eight patients. Pre-operatively, 10 patients had undergone at least one previous attempt at therapeutic pericardiocentesis. Pericardiectomy was performed where appropriate (thickened or inflamed). Results Of our 12 patients (50% male, median age 48 years, range 17–72 years), the underlying aetiology included idiopathic in five (41.6%), tuberculosis in four (33%), and malignancy in three patients (25%). Elective surgery was performed in nine patients. Median values of both central venous pressure and pulmonary capillary wedge pressure decreased markedly postoperatively (from 16.5 to 11.0 mmHg, p = 0.02; 20.0–15.0 mmHg, p = 0.01, respectively). There was no in-hospital mortality. Follow up ranged from three months to nine years (median three years). Five (41.6%) patients died during the follow-up period, and cumulative two-year survival was 55.6 ± 1.5%. Conclusion Pericardiectomy for ECP was effective, in terms of our early results, in patients unresponsive to medical therapy. Long-term survival depends on the underlying disease.

Aortic Valve Replacement for a Patient with Glucose‐6‐Phosphate Dehydrogenase Deficiency and Autoimmune Hemolytic Anemia

Abstract  Autoimmune hemolytic anemia and deficiency of glucose‐6‐phosphate deyhdrogenase (G6PD) result in severe hemolysis with different mechanisms. In patients with both pathologies, the effects of cardiopulmonary bypass on red blood cells and thrombocytes demand special care before and after open heart surgery. We evaluated the preoperative management and postoperative care of a patient with severe aortic insufficiency associated with G6PD deficiency and autoimmune hemolytic anemia who underwent aortic valve replacement.

Outcomes of Patients with Behçet's Syndrome after Pulmonary Endarterectomy

Background Behçets syndrome (BS) is a multisystem disorder and is not known as a risk factor for chronic thromboembolic pulmonary hypertension (CTEPH), for which the treatment of choice is pulmonary endarterectomy (PEA). The aim of this study was to review our experience in the surgical treatment of CTEPH in patients with BS. Methods Data were collected prospectively for consecutive patients with BS who underwent PEA over a 6‐year period. Results We identified nine patients (seven males, two females, mean age: 34.7 ± 9.9 years) with BS. The mean disease duration before PEA was 88.0 ± 70.2 months. All patients but one received immunosuppressive therapy before the surgery. Exercise‐induced dyspnea presented symptoms in six patients. One patient had associated intracardiac thrombosis. PEA was bilateral in five patients, unilateral in three, and lobar in one. No perioperative mortality was observed; however, one patient died four weeks after PEA due to massive hemoptysis. Morbidity was observed in two patients. The systolic pulmonary artery pressure fell significantly from 59.0 ± 22.7 mm Hg to 30.0 ± 6.5 mm Hg after surgery (p = 0.031). Pulmonary vascular resistance also improved significantly from 611.8 ± 300.2 to 234.7 ± 94.9 dyn/s / cm5 (p = 0.031). After a median follow‐up of 29.4 months, all patients improved to the New York Heart Association (NYHA) functional class I and II. Conclusion Patients with BS may suffer recurrent pulmonary embolism and develop CTEPH. In patients who do not respond to anticoagulation or immunosuppressive therapy, PEA may be a therapeutic option when thrombotic lesions are surgically accessible. Due to the high risk of perioperative mortality, the procedure should be undertaken in centers with experience.

Surgical treatment of aortic valve endocarditis: a26-year experience

Objective We have retrospectively analyzed the results of the operations made for aortic valve endocarditis in a single center in 26 years. Methods From June 1985 to January 2011, 174 patients were operated for aortic valve endocarditis. One hundred and thirty-eight (79.3%) patients were male and the mean age was 39.3±14.4 (9-77) years. Twenty-seven (15.5%) patients had prosthetic valve endocarditis. The mean duration of follow-up was 7.3±4.2 years (0.1-18.2) adding up to a total of 1030.8 patient/years. Results Two hundred and eighty-two procedures were performed. The most frequently performed procedure was aortic valve replacement with mechanical prosthesis (81.6%). In-hospital mortality occurred in 27 (15.5%) cases. Postoperatively, 25 (14.4%) patients had low cardiac output and 17 (9.8%) heart block. The actuarial survival rates for 10 and 15 years were 74.6±3.7% and 61.1±10.3%, respectively. In-hospital mortality was found to be associated with female gender, emergency operation, postoperative renal failure and low cardiac output. The long term mortality was significantly associated with mitral valve involvement. Male gender was found to be a significant risk factor for recurrence in the follow-up. Conclusion Surgery for aortic valve endocarditis has significant mortality. Emergency operation, female gender, postoperative renal failure and low cardiac output are significant risk factors. Risk for recurrence and need for reoperation is low.

166 Early results of patients with antiphospholipid syndrome and systemic lupus erythematosus following pulmonary endarterectomy

Background and aims Pulmonary hypertension is one of the most debilitating and fatal complications of systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS). These patients are prone to chronic thromboembolic pulmonary hypertension (CTEPH), for which the treatment of choice is pulmonary endarterectomy (PEA). It is a complex surgical procedure with removal of obstructive thromboembolic material from the pulmonary arteries in order to reduce pulmonary vascular resistance, relieve pulmonary hypertension (PH) and alleviate right ventricular dysfunction. Hereby, we share our clinical experience of PEA for CTEPH in SLE and APS patients. Methods Data were collected prospectively for consecutive patients with APS and SLE who underwent PEA over a 5 year period [2011–2016]. Case selection was made by consensus of a team consist of a cardiologist, pulmonologist, rheumatologist and thoracic surgeon. All the operations were performed by the same surgical team. Results We identified 22 patients (5 male, 17 female) with APS and SLE. Mean age was 35 (range=7 to 57). Median NYHA score was III (II to IV). Mean pulmonary artery pressure (mPAP) of the patients fell immediately from 77.4±30.8 mmHg to 28.8±8.9 mmHg right after surgery, and 31.2±7.5 mmHg on discharge. One (5.9%) patient developed acute respiratory distress syndrome and died on postoperative day 10. Mean follow-up duration was 31 months, with no additional mortality. Conclusions Patients with SLE and/or APS should be screened for CTEPH, since they are more susceptible to intravascular thrombosis. PEA is the treatment of choice for CTEPH patients, with its low morbidity and high success rates.

Frozen Elephant Trunk and Antegrade Visceral Debranching in the Surgical Treatment of Type B Aortic Dissection: An Alternative Method

Intervention is inevitable in complicated Type B aortic dissections. Classical surgical procedures and endovascular interventions are far from ideal treatments due to their high risk of periprocedural complications and mortality. There is often a need for alternative method in cases of difficult anatomy. We present the combined use of frozen elephant trunk and antegrade visceral debranching methods in the treatment of a 54-year-old male patient with complicated Type B aortic dissection.