Tankut Akay

Diaphragmatic paralysis after cardiac surgery in children: incidence, prognosis and surgical management.

Diaphragmatic paralysis (DP) after cardiac surgery is an important complication especially in infants. We analyzed the incidence, clinical course, surgical management and follow up of the patients with DP, retrospectively. Between 1996 and 2005, 3,071 patients underwent cardiac surgery. Total number of patients with DP was 152 (4.9%). Out of 152 patients, 42 were surgically treated with transthoracic diaphragm plication (1.3%). The overall incidence of diaphragm paralysis was higher in correction of tetralogy of Fallot (31.5%), Blaloc–Taussig (B–T) shunt (11.1%) and VSD closure with pulmonary artery patch plasty (11.1). The incidence of DP which require plication was higher in B–T shunt (23.8%) arterial switch (19%) and correction of tetralogy of Fallot (11.9%). Mean and median age at the time of surgery were 17.8±3.6 and 6 months, respectively. Median time from cardiac surgery to surgical plication was 12 days. Indications for plication were repeated reintubations (n=22), failure to wean from ventilator (n=12), recurrent lung infections (n=5) and persistent respiratory distress (n=3). Mortality rate was 19.1%. Being under 1 year of age, pneumonia and plication 10 days after mechanical ventilation were associated with higher incidence mortality (P<0.05). Phrenic nerve injury is a serious complication of cardiac surgery. It is more common after some special procedures. Spontaneous recovery is very rare. Being under 1 year of age, plication after 10 days from the surgery and pneumonia are major risk factors for mortality even in plicated patients. Transthoracic plication is helpful if performed early.

Mitral Valve Replacements in Redo Patients with Previous Mitral Valve Procedures: Mid‐Term Results and Risk Factors for Survival

Abstract  Objective: We aimed to investigate the risk factors for hospital mortality, short (five years) and mid‐term (10 years) survival in patients who underwent mitral valve replacements in redo patients with previous mitral valve procedures. Patients and Methods: Between September 1989 and December 2003, 62 redo patients have undergone mitral valve replacements due to subsequent mitral valve problems. Preoperative, operative, and postoperative data were analyzed retrospectively and evaluated for risk factors affecting hospital mortality, mid‐ and long‐term survival. Results: The hospital mortality was 6.4%. The one‐, five‐, and 10‐year actuarial survival rates were 94%± 2%, 89%± 6%, and 81 ± 9%. New York Heart Association (NYHA) functional class IV, low left ventricular ejection fraction (<35%), increased left ventricular end‐diastolic diameter (LVEDD) > 50 mm, female gender, pulmonary edema, and urgent operations were found to be risk factors in short‐term survival. NYHA functional class IV, low left ventricular ejection fraction, increased LVEDD, and increased left atrial diameter (LA > 60 mm) were risk factors in mid‐term survival. Conclusion: Redo mitral valve surgery with mechanical prosthesis offers encouraging short‐ and mid‐term survival. NYHA functional class IV, low left ventricular ejection fraction, and increased left ventricular diameters were especially associated with increased short‐ and mid‐term mortality. Earlier surgical management before the development of severe heart failure and myocardial dysfunction would improve the results of redo mitral valve surgery.

Successful Cardiac Transplantation From Donor With Carbon Monoxide Intoxication: A Case Report

BACKGROUND The use of hearts for cardiac transplantation from donors with brain death due to exposure to high concentrations of carbon monoxide is still under discussion. In this short report we have presented a patient who underwent a successful cardiac transplantation from a brain-dead donor who had cardiopulmonary resuscitation after carbon monoxide intoxication. METHOD A standard biatrial anastomosis technique was used in our patient. The transplantation was uneventful with donor ischemic time of 180 minutes. The patient was treated with mechanical ventilation for 72 hours. The donor liver biopsy during harvesting did not reveal irreversible changes. Although the donor had a history of cardiopulmonary resuscitation, the left ventricular ejection fraction was 55% and the echocardiographic evaluation revealed normal cardiac contractions with acceptable hemodynamic parameters. Positive inotropic support was needed in the early postoperative period. We did not observe any changes related to intoxication in the endomyocardial biopsy. CONCLUSIONS We concluded that successful heart transplantation can be performed using hearts from patients succumbing to carbon monoxide poisoning in the presence of adequate cardiac functional parameters. This group will increase the number of cardiac transplantations and decrease the incidence of deaths among patients on transplantation lists.

The Role of Antiendothelial Cell Antibodies in the Development and Follow-up of Coronary and Peripheral Arterial Diseases

Occlusive lesions in the arterial endothelium are often caused by formation of intimal hyperplasia and fibrinoid necrosis. The objective of this study was to investigate the association between antiendothelial cell antibodies (AECAs) and the development of coronary artery disease (CAD) and peripheral artery disease (PAD). In this study, 94 patients with CAD or PAD and 94 healthy volunteers serving as control subjects were examined. Frozen sections of human umbilical vein endothelial cells and primate smooth muscle cells were used to detect the presence of AECAs, which were found in 52 of 94 patients (55%) and in 15 of 94 controls (16%) (P < .001). Endothelial structure tissue damage is a major factor in arterial diseases. In the present study, a statistically significant relationship was found between AECAs and the development of CAD and PAD. The presence of AECAs has been identified as a risk factor for these diseases. According to this study, AECAs are reliable prognosticators for the development of CAD and PAD. Further studies with large numbers of serum samples are under way.

Risk factors for postoperative arrhythmia in patients with physiologic univentricular hearts undergoing Fontan procedure

OBJECTIVE Advanced age, dilated right atrium, increased preoperative pulmonary artery pressure, increased right atrial pressure, technique of operation, and poor ventricular function were reported to be risk factors for postoperative arrhythmia. Aim of this study is to determine the risk factor for postoperative arrhythmia after Fontan operation with regard to ventricle dominancy and hemodynamic parameters. METHODS In this retrospective study, the data of the patients including age, weight, dominant ventricle, type of cardiac anomaly, previous operations, duration of cardiopulmonary bypass (CPB), duration of aortic clamping, cardiac rhythm, pulmonary artery pressure, the Nakata Index, systemic atrioventricular (AV) valve insufficiency were obtained from the hospital records, the echocardiographic files, and cardiac catheterization records. Patients were assigned to dominant left ventricle or dominant right ventricle groups. Statistical analysis was performed using the Mann-Whitney U test. RESULTS Arrhythmia was observed in 21 (52.5%) patients in the postoperative period. No postoperative arrhythmia was observed in patients with a right atrial pressure of <5 mmHg, whereas postoperative arrhythmias were observed in patients with a right atrial pressure of ≥5 mmHg (p<0.05). When the effects of preoperative and postoperative pulmonary artery pressures on postoperative arrhythmia were evaluated, postoperative arrhythmia was determined in only 2 (12.5%) of 8 patients with a preoperative mean pulmonary artery pressure of ≤9 mmHg, whereas postoperative arrhythmia was observed in 19 (59.3%) of 32 patients with a preoperative pulmonary artery pressure of ≥10 mmHg. A preoperative mean pulmonary artery pressure of >10 mmHg increased the risk of postoperative arrhythmia (p<0.02). Postoperative arrhythmia was determined in 8 (53%) of 15 patients with a dominant right ventricle, and in 13 (52%) of 25 patients with a dominant left ventricle (p>0.05). CONCLUSION While a preoperative mean pulmonary artery pressure of >10 mmHg and a preoperative right atrial pressure of >5 mmHg were the risk factors for postoperative arrhythmia in patients undergoing Fontan procedure, the right or left ventricular dominance was not a risk factor.

Coronary Bypass Surgery in Kawasaki Disease in a Four-Year-Old Patient: Case Report

Abstract  Kawasaki disease is an acute vasculitis syndrome of unknown etiology that mainly affects small and medium‐sized arteries, particularly the coronary arteries. This disease is rarely seen in infants and young people in Turkey. In this short report, we present a four‐year‐old patient who has Kawasaki disease associated with coronary artery aneurysm and underwent coronary bypass grafting.

The Midterm Results of Cardiac Transplantation Patients

OBJECTIVE Cardiac transplantation is an important treatment option that increases the survival and decreases the limitations in effort capacity among patients with end-stage heart disease. In this study we have presented the midterm results of 13 patients who underwent cardiac transplantation between 2003 and 2007. PATIENTS AND METHODS There were 10 male and three female patients of mean age of 32 +/- 13.27 years (12 to 54). In one patient, we performed combined cardiac and renal transplantation. Ischemic cardiac disease was present in six patients and cardiomyopathy in seven patients. The mean age of the donors was 23.3 +/- 11.8 years (12 to 46). Corticosteroids, cyclosporine, and mycophenolate mofetil were used for immunosuppression. Sirolimus was employed in five cases due to impaired renal function. Patients were followed by echocardiography, endomyocardial biopsy, and dobutamine stress echocardiography. RESULTS The mean follow-up was 18.6 +/- 13.4 (1 to 38) months. In four patients, there was grade IIIA (II-R) rejection. In five patients, tacrolimus or cyclosporine was replaced with sirolimus due to elevated creatinine levels. Dobutamine stress echocardiography was positive in one patient, who displayed a severe left main coronary artery lesion. There was no operative mortality. There was only one hospital mortality (7.6%). Two patients died in the midterm. The overall mortality on follow-up was 3 (23.1%). The survival rates in the first, second, and third years were 92%, 88%, and 75%, respectively. Ejection fraction were more than 50%; all of posttransplant survivors showed good effort capacity. CONCLUSION Cardiac transplantation is a definitive, safe, and effective treatment for patients with end-stage heart failure.

Regional anesthesia in elderly patients undergoing carotid surgery: report of a case series.

Background: This study evaluates the short-term results in patients more than 75 years of age undergoing carotid endarterectomy at a single institution. Methods: Between June 2004 and June 2007, carotid endarterectomy operations were performed in 123 patients. A total of 70 patients had regional anesthesia. The data for all patients were retrospectively reviewed. Regional anesthesia and selective shunting was performed in all patients. Results: In 6 patients, a shunt was required. Primary closure of the carotid artery was performed in 22 patients and patch angioplasty was used in the remainder. There were no postoperative neurological complications. One patient died due to myocardial infarction. Conclusions: Carotid endarterectomy with regional anesthesia can be performed safely in the elderly population with low mortality and morbidity. Regional anesthesia may have advantages over general anesthesia and could potentially aid in avoiding complications related to shunt use.

Massive ascites due to right heart failure after cardiac transplantation and its treatment: a case report.

Ascites is a common clinical condition during right heart failure. In this short report we have presented a patient with massive ascites due to right heart failure after cardiac transplantation who was previously operated for Ebsteins anomaly and pulmonary stenosis as well as mitral and tricuspid valve repairs. Right heart failure increases the accumulation of ascites which decreases the preload of the heart and cardiac output. Aggressive paracentesis may be a definitive solution for this type of patient.