Taylan Adademir

Intravenous iloprost for treatment of critical limb ischemia in patients unsuitable for revascularization

Introduction Whether medical therapy alone may reduce the amputation rates in patients with chronic limb ischemia and who are unsuitable for revascularization is a controversial topic. In this study, we aimed to investigate the effects of 1 week infusion of iloprost in the treatment of patients with chronic limb ischemia. Materials and methods Twenty-seven consecutive patients were included in the study. There were 23 men (85.2%) and 4 women (14.8%) with a mean age of 68.93 ± 14.84 years. Patients were considered eligible if they were unsuitable for surgical and endovascular revascularization. Follow-up was made on 10th day and 6th month and included ankle brachial index and clinical assessment. Results Minor side effects occurred in four patients (16.0%), but the treatment was continued. In-hospital mortality occurred in one patient (4.0%). Another two patients died and four patients received amputation until follow-up (overall mortality 11.1%). There was significant increase in mean ankle-brachial index values between 1st day and 10th day (p < 0.001), between 1st day and 6th month (p < 0.001), and between 10th day and 6th month (p < 0.001). Conclusion One-week treatment with iloprost may provide both long lasting symptomatic benefit and may improve hemodynamic parameters, which were shown to predict future amputation.

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.

Should a Cardiac Surgeon Blame Himself for Replacing a Mitral Valve

and learned a lot about the importance of repair for mitral valve. Besides, we have attended a lot of meetings describing several repair techniques for different pathologies. Both European and American guidelines offer mitral valve repair whenever it is possible and they even do not suggest surgery under some circumstances if the likelihood of successful repair is not more than 95%. Papers from Europe and United States declare up to 70% repair rate for mitral valve and the trend is increasing each year. Is it the case for us? As junior cardiac surgeons, we feel sorry for each valve we replace in our centre. That’s why we checked our databases to answer the question, “what are we doing to the mitral valve?” The result was far beyond the results of developed countries. We repaired 28% of mitral valves in 2014. This was almost 50% more than the year 2012 as we repaired only 20% of mitral valves but still too low. Low for whom? Developed countries... In a speech during the 28 European Association for CardioThoracic Surgery Annual Meeting, Maldonado reported the rate of mitral repair in Latin America, and the results were almost the same as ours. Surgeons in Colombia, Chile, Mexico and Brazil repaired 30%, 32%, 39% and 42% of mitral valves, respectively, during 2013. What does this mean? Developing surgeons! Don’t they know how to repair mitral valves in developing countries? It shouldn’t be the case as each of the above countries has worldwide known and experienced surgeons, for example, the Brazilian Cardiac Surgery Society has more than 1200 surgeons performing around 70 thousand cardiac operations every year. Etiology of mitral valve disease is the most probable answer for the difference between developing and developed countries. Degenerative mitral valve regurgitation is the most suitable target for repair. Euro Heart Survey revealed that 72% of mitral valve diseases were pure mitral regurgitation and the majority (61%) of etiology was degenerative disease of the valve. On the other hand, the Turkish registry of heart valve disease showed that only 30% of pure mitral regurgitation was due to EDITORIAL

Regional cervical plexus blockage for carotid endarterectomy in patients with cardiovascular risk factors.

BACKGROUND Carotid artery disease is not rare in cardiac patients. Patients with cardiac risk factors and carotid stenosis are prone to neurological and cardiovascular complications. With cardiac risk factors, carotid endarterectomy operation becomes challenging. Regional anesthesia is an alternative option, so we aimed to investigate the operative results of carotid endarterectomy operations under regional anesthesia in patients with cardiac risk factors. METHODS We aimed to analyze and compare outcomes of carotid endarterectomy under regional anesthesia with cardiovascular risk groups retrospectively. Between 2006 and 2014, we applied 129 carotid endarterectomy ± patch plasty to 126 patients under combined cervical plexus block anesthesia. Patients were divided into three groups (high, moderate, low) according to their cardiovascular risks. Neurological and cardiovascular events after carotid endarterectomy were compared. RESULTS Cerebrovascular accident was seen in 7 patients (5.55%) but there was no significant difference between groups (P > .05). Mortality rate was 4.76% (n = 6); it was higher in the high risk group and was not statistically significant (P = .180). Four patients required revision for bleeding (3.17%). We did not observe any postoperative surgical infection. CONCLUSION Carotid endarterectomy can be safely performed with regional cervical anesthesia in all cardiovascular risk groups. Comprehensive studies comparing general anesthesia and regional anesthesia are needed.

A Perplexing Presentation of Entrapment of the Brachial Artery.

A 45-year-old male being otherwise healthy presented acute onset of right upper extremity ischemia. On physical examination, axillary artery could be palpated whereas the brachial artery could not be palpated below the level of the antecubital fossa, including radial and ulnar artery pulses. Pulses were also inaudible with pocket-ultrasound below the level of the brachial artery bifurcation. The patient was initially diagnosed to have acute thromboembolic occlusion and given 5000 IU intravenous heparin. The patient was taken to the operating room. We noticed that the ischemic symptoms disappeared within a couple of minutes just before we began the operation. However, ischemic symptoms reappeared six hours later and computed tomography angiography showed lack of enhancement below the elbow crease. We were taking the patient to the operating room for the second time when the symptoms recovered in a few minutes, again. The operation was not canceled anymore. In the operation, the brachial artery was found anomalously perforating and it was entrapped by the bicipital aponeurosis. The artery was relieved by resecting the aponeurosis and there was no need for any other intervention. The patient had no more recurrence of symptoms postoperatively.

Validation of EuroSCORE II risk model for coronary artery bypass surgery in high-risk patients

Introduction Determining operative mortality risk is mandatory for adult cardiac surgery. Patients should be informed about the operative risk before surgery. There are some risk scoring systems that compare and standardize the results of the operations. These scoring systems needed to be updated recently, which resulted in the development of EuroSCORE II. In this study, we aimed to validate EuroSCORE II by comparing it with the original EuroSCORE risk scoring system in a group of high-risk octogenarian patients who underwent coronary artery bypass grafting (CABG). Material and methods The present study included only high-risk octogenarian patients who underwent isolated coronary artery bypass grafting in our center between January 2000 and January 2010. Redo procedures and concomitant procedures were excluded. We compared observed mortality with expected mortality predicted by EuroSCORE (logistic) and EuroSCORE II scoring systems. Results We considered 105 CABG operations performed in octogenarian patients between January 2000 and January 2010. The mean age of the patients was 81.43 ± 2.21 years (80-89 years). Thirty-nine (37.1%) of them were female. The two scales showed good discriminative capacity in the global patient sample, with the AUC (area under the curve) being higher for EuroSCORE II (AUC 0.772, 95% CI: 0.673-0.872). The goodness of fit was good for both scales. Conclusions We conclude that EuroSCORE II has better AUC (area under the ROC curve) compared to the original EuroSCORE, but both scales showed good discriminative capacity and goodness of fit in octogenarian patients undergoing isolated coronary artery bypass grafting.

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.

Successful emergency double valve repair operation during acute aortic dissection type A.

Reconstructive valve surgery in acute aortic dissection type A (AADTA) remains challenging. We describe a case of successful combined repair of the aortic and mitral valves, and replacement of the ascending aorta after AADTA with aortic and mitral insufficiency. Mitral valve repair was achieved by quadrangular resection of the posterior leaflet, combined with ring annuloplasty. Aortic valve repair was achieved by Cabrol commissural sutures with resuspension of the annulus. The postoperative clinical course was uneventful and an echocardiogram revealed competent mitral and aortic valves. Mitral and aortic valve repair is an option in AADTA with mitral and aortic valve insufficiency.

Factors associated with early mortality in haemodialysis patients undergoing coronary artery bypass surgery

Summary Introduction: Coronary artery bypass grafting (CABG) results in higher morbidity and mortality rates in end-stage renal disease (ESRD) patient populations than in patients with normal renal function. This study aimed to identify the early results of CABG performed on ESRD patients, and the factors that affected the mortality rates of those patients. Methods: A retrospective evaluation of our hospital database revealed 84 haemodialysis-receiving patients who underwent CABG during the years 2006 to 2012. Mortality was observed in 21 patients (group 1), and this group was compared with the remaining patients (group 2) for peri-operative parameters such as age, EuroSCORE, functional capacity, myocardial infarction, use of inotropes and completeness of revascularisation. Results: The study included 60 male (71.4%) and 24 female patients (28.6%); the participants’ mean age was 59.50 ± 9.93 years. The pre-operative additive EuroSCORE was 7.96 ± 2.88 (range: 2–18). Pre-operative functional capacity was impaired in 35.7% of the patients [New York Heart Association (NYHA) classes III–IV]. Mean age and preoperative EuroSCORE values of group 1 were significantly higher than those of group 2. Impaired functional capacity (NHYA classes III–IV) was also associated with mortality (OR: 3.333; 95% CI: 1.199–9.268). Fifty-four patients (64.3%) underwent on-pump CABG procedures, and 30 (35.7%) underwent off-pump CABG procedures. The study found no statistically significant difference in mortality rates between these two techniques. Mortality occurred in 12 patients (22.2%) in the on-pump group and in nine (30%) in the off-pump group. Complete revascularisation was performed on 46 patients (85.2%) in the on-pump group and seven (23.3%) in the off-pump group (p < 0.001). Conclusion Advanced age, impaired NYHA functional capacity and pre-operative hypertension were determinative for early-term surgical mortality. An on-pump surgical technique is recommended to ensure completeness of revascularisation.

Comparison of Early Outcomes with Three Approaches for Combined Coronary Revascularization and Carotid Endarterectomy

Objective This study aims to compare three different surgical approaches for combined coronary and carotid artery stenosis as a single stage procedure and to assess effect of operative strategy on mortality and neurological complications. Methods This retrospective study involves 136 patients who had synchronous coronary artery revascularization and carotid endarterectomy in our institution, between January 2002 and December 2012. Patients were divided into 3 groups according to the surgical technique used. Group I included 70 patients who had carotid endarterectomy, followed by coronary revascularization with on-pump technique, group II included 29 patients who had carotid endarterectomy, followed by coronary revascularization with off-pump technique, group III included 37 patients who had coronary revascularization with on-pump technique followed by carotid endarterectomy under aortic cross-clamp and systemic hypothermia (22-27ºC). Postoperative outcomes were evaluated. Results Overall early mortality and stroke rate was 5.1% for both. There were 3 (4.3%) deaths in group I, 2 (6.9%) deaths in group II and 2 (5.4%) deaths in group III. Stroke was observed in 5 (7.1%) patients in group I and 2 (6.9%) in group II. Stroke was not observed in group III. No statistically significant difference was observed for mortality and stroke rates among the groups. Conclusion We identified no significant difference in mortality or neurologic complications among three approaches for synchronous surgery for coronary and carotid disease. Therefore it is impossible to conclude that a single principle might be adapted into standard practice. Patient specific risk factors and clinical conditions might be important in determining the surgical tecnnique.