Yuksel Besir

Choice of incision in penetrating cardiac injuries: Which one must we prefer: Thoracotomy or sternotomy?

BACKGROUND Penetrating cardiac injuries are high-risk, high-mortality injuries considering the outcomes. Therefore, it is important to choose the appropriate incision. In general clinical settings, thoracotomy and median sternotomy are choices of incisions to explore the injury. In this study, the results of median sternotomy and thoracotomy in penetrating cardiac injuries were compared. METHODS Between January 2003 and December 2013, forty patients, who underwent either thoracotomy or median sternotomy for penetrating cardiac injury, were retrospectively analyzed, and the collected data were compared. Twenty-six patients underwent thoracotomy (Group 1), and fourteen patients underwent median sternotomy (Group 2). RESULTS There was no statistically significant gender difference between the groups. However, the mean age in Group 2 was found to be significantly higher than the one in Group 1 (p<0.05). CONCLUSION There were no significant survival differences between the groups in the long term. Incision choice should be determined considering the site of injury and whether there is an accompanying pulmonary injury or not. On the other hand, thoracotomy has some draw backs compared to median sternotomy.

Complications of Cannulation in Extracorporeal Membrane Oxygenation

the successful treatment of AEF, andwehope that the previously mentioned comments might add to the value of the article by Kahlberg et al. Kadir Ceviker Mustafa Demirer Ahmet Kupeli Abdulkadir Yildiz Rasih Yazkan Faculty of Medicine, Department of Cardiovascular Surgery, Suleyman Demirel University, Isparta, Turkey Faculty of Medicine, Department of Forensic Medicine, Suleyman Demirel University, Isparta, Turkey Faculty of Medicine, Department of Thoracic Surgery, Suleyman Demirel University, Isparta, Turkey E-mail: kadir.ceviker@sdu.edu.tr

About the Impact of Extracardiac Vascular Disease on Vein Graft Failure

1. Nagendran J, Norris CM, Graham MM, et al. Coronary revascularization for patients with severe left ventricular dysfunction. Ann Thorac Surg 2013;96:2038–44. 2. Weintraub WS, Grau-Sepulveda MV, Weiss JM, et al. Comparative effectiveness of revascularization strategies. N Engl J Med 2012;366:1467–76. 3. Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS); European Association for Percutaneous Cardiovascular Interventions (EAPCI), , Kolh P, Wijns W, Danchin N, et al. Guidelines on myocardial revascularization. Eur J Cardiothorac Surg 2010;38(Suppl):S1–52.

Effect of obesity on postoperative outcomes in patients with left ventricular assist device

We congratulate Volkovicher and colleagues for their successful study [1]. We found the main outcome of their study very interesting that obesity is not a risk factor for mortality in patients with left ventricular assist device (LVAD). Even as the authors have briefly stated in the discussion section, obesity does not seem to be a risk factor for mortality in similar studies with LVAD patients [2, 3]. However, this does not exactly coincide with our current knowledge of the general outcome of the cardiac surgery. Because obesity is described as a risk factor for mortality in many studies involving cardiac surgery without any LVAD patient [4–6]. In many of these studies, apart from mortality rate, the negative effects of obesity on many parameters such as re-hospitalization, the incidence of postoperative surgical infection, prolonged duration of stay in the intensive care unit, prolonged ventilation, and the incidence of postoperative renal failure have been reported. In the authors’ study, obesity does not seem to be a problem in terms of mortality and many of these parameters. But, the remarkable expression in these studies we have exemplified is “extreme obesity”. So, the main issue mentioned in these studies is extremely high body mass index (BMI). In fact, in the authors’ study, mortality rate is also seen to increase somewhat as the BMI increases. Is not there too much generalization in this context while reporting that obesity has no effect on mortality? Would not it be more appropriate to emphasize that the situation is different in obese patients with morbid obesity? We believe that learning about the authors’ ideas on this subject will add value to their study.

Effects of Blood Transfusion on Long-Term Survival of Cardiac Surgery Patients

instability, such as left ventricular pump function, the presence of pericardial effusion, or coronary dissection, were statistically similarly distributed between the two groups after propensity score matching. Also, our experience shows that axillary cannulation can be rapidly and safely performed using the Fem-Flex cannula (Edwards Lifesciences, Irvine, CA) even in hemodynamically unstable patients with the need for a rapid cannulation and cardiopulmonary bypass support, whereas aortic cannulation is frequently associated with difficulties identifying the true lumen, particularly in cases of circumferential dissection of the ascending aorta. Despite all that, further bias and confounders in terms of patient selection and their treatment cannot be excluded. Also, the retrospective design of this study and a relatively small patient cohort analyzed represent the main limitations of the study decreasing statistical power of the propensity score matching. In this respect, we agree that our results should be interpreted with caution before further evidence is available.

Extracorporeal cardiopulmonary resuscitation after pediatric cardiac surgery

We genuinely appreciate Erek et al. (1) for their study. Extracorporeal cardiopulmonary resuscitation (ECPR) has become a widely used procedure in cardiac arrest situations. The authors should definitely admit this procedure if they use cardiac arrest after pediatric cardiac surgery, a highly catastrophic condition. We believe that their results are very successful considering that the rate of post-cardiopulmonary bypass without cardiac arrest after discharge from the hospital is 20%–45% (2-4). However, we want to comment on a different topic. We believe that some obvious complications could have developed because of cannulation sites utilized by the authors. Because the ascending aorta is placed in the outlet cannula, left ventricular failure can be triggered by increasing afterload. Heart failure after ECPR is almost inevitable because of systemic phenomena caused by heart failure due to cardiac arrest in patients in the study by Erek et al. (1). Our questions to Erek et al. (1) are focused on this stage. If the causes of cardiac arrest in patients can be determined, what is the rate of heart failure in these patients? Further, if heart failure occurs, does it affect survival after ECPR? We would be very grateful if the authors have any explanation for these questions.

What Kind of Incision Should be Used in Thoracic Trauma Patients in Emergent Cases

We would like to mention that we have read the study with great interest [1]. Different kinds of incisions are being used for resuscitative approach as well as emergent cases without the need for resuscitation. As the authors indicated, both clamshell and left lateral thoracotomy are ideal incisions especially for resuscitative approach. Flaris et al. underlined that clamshell incision does not cause time loss. But another question that should be of concern is which incision provides the easiest access to injury. In this aspect, we think that these two incisions should be compared with sternotomy when it comes to cardiac traumas without the need for resuscitation. In addition to that, study of Beşir et al. revealed that both thoracotomy and sternotomy were used in cardiac trauma patients [2], and it was mentioned that sternotomy could be added to patients with thoracotomy, and vice versa. The reason for that is in patients with sternotomy, thoracotomy could be needed for lung injuries and in patients with thoracotomy, sternotomy could be needed for particular cardiac and major vascular injuries. It is obvious that both cardiac and lung injuries can be handled with clamshell incision, but in need of cardiopulmonary bypass, cannulation can present a challenge in cardiac or major vascular injuries. Thus, we think that it is an individual debate that which of these three incisions has more advantage in cardiac and lung traumas without the need for resuscitation. We suggest that the study will be more valuable if the authors share their point of view about this subject.

Surgical approach to vascular iatrogenic injuries in pediatric cases

BACKGROUND Surgical intervention is mandatory in many children who present with vascular trauma or in complicated cases after medical interventions. In this study, surgical interventions applied after vascular injuries in children were analyzed. METHODS Between January 2002 and December 2012, 17 patients (aged under 18) who were admitted to the emergency room with vascular injuries were retrospectively analyzed. The data was collected through hospital records. Preoperative and postoperative data of the patients were recorded and analyzed. RESULTS Of the total, 11 patients were female (64.7%) and 6 patients were male (35.3%) with a range of 4-192 months. In total, 14 (82.3%) injuries were due to angiographic interventions, 1 (5.9%) was due to external trauma, 1 (5.9%) was due to preoperative trauma, and 1 (5.9%) was due to a catheterization complication in the intensive care unit. Additionally, 11 (64.7%) injuries were located in the right femoral artery, 3 (17.6%) were located in the left femoral artery, 2 (11.8%) were located in the left brachial artery, and 1 (5.9%) was located in the left external iliac vein. Also, 5 (29.4%) patients were managed under local anesthesia and 12 (70.6%) patients were managed under general anesthesia. With respect to treatment, 15 (88.2%) injuries were repaired with primary sutures, 1 (5.9%) injury was repaired with an end-to-end anastomosis, and 1 (5.9%) injury was repaired with a saphenous vein graft interposition. In addition, 16 (94.1%) patients underwent a thrombectomy prior to the repair. The total hospital stay was calculated as 2.7±1.4 days. The intensive care unit stay was calculated as 1.1±0.4 days. There was no mortality, a loss of an injured extremity, or an infection. No other complication was detected. CONCLUSION Iatrogenic interventional procedures seem to be responsible for the majority of pediatric vascular injuries. The results of surgical repairs in these injuries are successful and efficient.

Postoperative cognitive dysfunction markers in coronary artery surgery.

We congratulate Özturk et al. (1) on their study entitled “Effect of the type of cardiopulmonary bypass pump flow on postoperative cognitive function in patients undergoing isolated coronary artery surgery” published for the Anatolian Journal of Cardiology 2016 May 9 as an Epub ahead of print. We believe that we can offer the authors some points that will contribute to their study in which they compared use of pulsatile and non-pulsatile pumps in terms of post-operative cognitive dysfunction (POCD). Firstly, although the study is prospective, not very many data about the patients were analyzed. Some factors that are predictors of POCD should have been compared between the 2 groups. For example, we see that the authors did not analyze hypertension, diabetes mellitus, duration of operation, period of anesthesia, preoperative low ejection fraction, low effort capacity, or preoperative European system for cardiac operative risk evaluation levels, which are described as predictor factors for POCD in several studies (2, 3). In order to compare the 2 groups, it should have been reported that there was no difference on the basis of these parameters. The authors, inspired by some previous studies, analyzed levels of S100β and neuron-specific enclose biomarkers, which they thought might be associated with POCD. However, one of the most-used biomarkers in the literature associated with POCD is serum cortisone level (4). We are of the opinion that if the authors provide us with their ideas on this subject and if they can share any available data for these parameters, it will surely add value to their study.

An alternative method of transperitoneal graft introduction in aortobifemoral bypass surgery.

Summary Introduction Intestinal injury and bleeding, which usually occurs while taking the graft through the transperitoneal tunnel, is one of the most important complications of aortobifemoral bypass surgery. In this study, case reports were examined where, for some reason, the tunneller instrument could not be used to create the transperitoneal tunnel and the tunnelling forceps was used. In some of these cases, the grafts were taken through conventionally and in others an alternative method was used. Methods Between 2002 and 2013, the records of 81 patients treated surgically by aortobifemoral bypass for peripheral arterial disease, were investigated retrospectively. In the conventional method, after creating a tunnel with tunnelling forceps, the forceps was re-introduced into the tunnel and the graft was clasped and brought through the tunnel. In the alternative method, a nylon tape was left as a guide in the tunnel while creating the tunnel, and the forceps was not introduced again. The graft was taken through the tunnel with the help of the nylon tape. Patients treated with the conventional method were included in group 1 (n = 49) and patients in which the graft was guided with nylon tape were included in group 2 (n = 32). The groups were compared peri-operatively. Results There were no significant differences between the groups in terms of co-morbidity factors. Extubation time, intensive care length of stay, revision for bleeding, other postoperative complications, and infection and late-term infection rates were similar in the two groups (p > 0.05). Hospital length of stay and blood usage were significantly higher in group 1 (p < 0.05). Drainage amounts were higher in group 1 but not statistically significant. Conclusion Using nylon tape to introduce the graft into the femoral area during aortobifemoral bypass operations was found to be more effective than using the tunnelling forceps.