©2019 All right reserved by the Turkish Society of Cardiovascular Surgery. Arıtürk C, Baran R, Kara S. A complex aortic arch anomaly: A rarely seen image. Turk Gogus Kalp Dama 2019;27(3):414-415 Cite this article as: A 56-year-old female patient was admitted to our hospital with cough and mild dyspnea during daytime. She was previously admitted to neurology and orthopedics clinics several times with left arm pain. After physical examination and basic clinical assessment, a contrasted computed tomography of the chest was performed which revealed a complex aortic arch anomaly. The first branch of the arch was the trunk of bilateral common carotid arteries and, just before the joint of the aortic arch and descending aorta, the Kommerell diverticulum (KD) was visible. In the 6-cm distal the origin of left subclavian artery (LSA), there was 140o fold in the route of the LSA. There was an aortic coarctation resulting in 20% aortic stenosis in size (Figure 1). The third branch of the aortic arch, aberrant right subclavian artery (ARSA), was arising from the medial part of the coarctated part of aorta, reaching the right arm after a retrotracheal route (Figure 2).

In this study we aimed to evaluate the effects of dilutional anemia resulting from cardiopulmonary bypass (CPB) and its correction with red blood cell (RBC) transfusion on tissue oxygenation and renal function in diabetic patients undergoing coronary artery bypass grafting (CABG).

Despite the increased risk for adverse outcomes, patients with chronic kidney disease (CKD) presenting with coronary artery disease are less likely to receive evidence-based therapies. Several studies demonstrated that anemia and blood transfusions are both risk factors for mortality, while others argue that it is preoperative anemia -rather than RBC transfusion itself- that is harmful. There is still a gap to adequately address this issue especially in patients with CKD.

The present study aimed to evaluate the late-term changes in radial artery luminal diameter (RAD) and vasodilatation response following transradial catheterization (TRC). TRC-inducing trauma to radial artery intima may trigger chronic phase vascular changes and lead to anatomical and functional impairment. There is controversial data whether the impairment persists or repairs later. Fifty-six consecutive patients undergoing TRC were enrolled prospectively. Baseline RAD, flow-mediated dilatation (FMD) and nitroglycerin-mediated dilatation (NMD) of the radial artery at the access site were measured before TRC by high-resolution ultrasound. Six months later; RAD, FMD and NMD were measured again at the same access site. RAD at the sixth month was reduced compared with pre-procedural measurements (2.85 ± 0.44 versus 2.74 ± 0.42 mm, p = 0.0001).The average FMD decreased to 5.66 ± 5.87 %, which was significantly lower than the observed pre-procedural FMD (9.45 ± 5.01 %) 6 months after TRC (p = 0.0001). Likewise, the average NMD at the sixth month was reduced compared with pre-procedural NMD (9.52 ± 6.77 versus 6.64 ± 6.51 %, p = 0.018). Logistic regression analysis indicated that pre-procedural radial artery diameter to sheath size ratio was the independent predictor of NMD reduction (95 % confidence interval, β = −9.74, p = 0.024). TRC may lead to a significant luminal diameter reduction and impairment of vasodilatation response in the radial artery at late term.

BACKGROUND/AIM:The aim of the current study was to assess the accuracy of cardiac output (CO) measurements obtained by the Nexfin finger cuff method as compared with the FloTrac/Vigileo and echocardiography methods in coronary artery bypass grafting (CABG) patients.MATERIALS AND METHODS:First-time elective CABG patients were prospectively enrolled in this study and divided into three groups according to CO measurement method. CO measurements were performed simultaneously by three different contributors and were collected by the fourth one 24 h postoperative in the intensive care unit (ICU). Data were statistically analyzed.RESULTS:Seventeen female and 13 male patients between 42 and 78 years of age (with a mean of 56 ± 4) were the subjects of this study. The mean CO measurements were 5.9 ± 1.4 L/min, 5.8 ± 1.1 L/min, and 6.0 ± 1.1 L/min for the Nexfin, FloTrac/Vigileo, and echocardiography methods, respectively (P > 0.05). The correlation values between Nexfin and FloTrac/Vigileo, Nexfin and echocardiography, and FloTrac/Vigileo and echocardiography were r = 0.445, r = 0.377, and r = 0.384, respectively (P < 0.05).CONCLUSION:Nexfin yielded results comparable to those obtained with FloTrac/Vigileo and echocardiography for the postoperative CO assessment of CABG patients. Nexfin may be used in uncomplicated, hemodynamically stable patients in ICU as a reliable and totally noninvasive method of CO measurement.

Thoracic endovascular aortic repair is used to treat complicated type B dissections. A 62-year-old male patient was admitted to our cardiovascular surgery clinic with chest pain. Contrast thoracic tomography showed chronic type B dissection, proximal advance of type B aortic dissection beginning distally to the origin of the left subclavian artery. Endovascular intervention was planned. Transesophageal echocardiography was used to verify the true and false lumens during procedure. In conclusion, angiographic examination may not be sufficient to differentiate the true and the false lumens of the aorta. Therefore, transesophageal echocardiography may be used to verify the true lumen of the thoracic descending aorta.

ÖZ Amaç: Bu çalışmada ekstrakorporeal dolaşım uygulanan elektif açık kalp cerrahisi hastalarında, mikro dolaşımın bozulma potansiyeli en fazla olan dönemin ve mikro dolaşım ile ilişkili olan diğer hemodinamik ve kan gazı parametrelerinin belirlenmesi amaçlandı. Ça­lış­ma­ pla­nı:­ İlk kez elektif açık kalp cerrahisi yapılması planlanan 20 erişkin hasta (12 erkek, 8 kadın; ort. yaş 56.4 yıl dağılım: 38-77 yıl) prospektif olarak çalışmaya alındı. Doku oksijen satürasyonu, kalp hızı, nabız oksimetresi, elektrokardiyografi, invaziv arteriyel kan basıncı monitörizasyonu, bispektral indeks ve serebral rejyonel oksijen satürasyonu monitörizasyonları yapıldı. Anestezi indüksiyon öncesi, ameliyat sırası ve ameliyat sonrası dönemlerde ölçümler tekrarlandı ve kaydedildi. Bul gu lar: Ameliyat sırası dönemde, hastaların en düşük doku oksijen satürasyonu değerleri ile sağ ve sol serebral rejyonel oksijen satürasyonu yüzde değişim değerleri ısınma döneminde tespit edilmiş olup, sırasıyla %69±2, –%17±2, –%14±2 idi. Ameliyat sonrası dönemde ise en düşük değerler ameliyat sonrası birinci saatte olup değerler sırasıyla %59±2, –%15±4, –%12±3 idi. Doku oksijen satürasyonu, laktat ve serebral rejyonel oksijen satürasyonu değerlerinde gözlenen düşüşler birbirleri ile anlamlı ilişki gösterdi (p<0.05). So­nuç:­ Hipotermi, hemodilüsyon ve nonpulsatil akımın olduğu ekstrakorporeal dolaşım sırasında ve sonrasında mikro dolaşım bozulabilmekte; ancak, bu standart izlem parametreleri ile zamanında tespit edilememektedir. Standart monitörizasyona ilave olarak doku oksijen satürasyonu takibi ile mikro dolaşımın değerlendirilmesinin sonuç parametreleri açısından anlamlı olacağı kanısındayız. Anah­tar­söz­cük­ler: Ekstrakorporeal dolaşım; mikro dolaşım; doku oksijen satürasyonu. ABSTRACT Background:­ In this study, we aimed to identify the potential period which microcirculation tends to mostly deteriorate and other hemodynamic and arterial blood gas parameters associated with microcirculation in patients undergoing elective open heart surgery with extracorporeal circulation. Methods: Twenty adult patients (12 males, 8 females; mean age 56.4 years; range 38 to 77 years) who were scheduled for elective first-time open heart surgery were prospectively included in the study. Tissue oxygen saturation heart rate, pulse oximetry, electrocardiography, invasive arterial blood pressure monitoring, bispectral index, and regional cerebral oxygen saturation monitoring were performed. Measurements were repeated and recorded before anesthesia induction, preoperatively, and postoperatively. Results:­ The lowest tissue oxygen saturation values and the highest % alteration of the right and left regional cerebral oxygen saturation were in the re-warming period perioperatively with 69±2%, –17±2%, –14±2%, respectively. The lowest values in postoperative period were measured at the postoperative first hour with 59±2%, –15±4%, –12±3%, respectively. Reductions in the tissue oxygen saturation, lactate and regional cerebral oxygen saturation values were statistically significantly correlated with each other (p<0.05). Conclusion:­ Hypotermia, hemodilution and nonpulsatile flow during and after extracorporeal circulation may deteriorate microcirculation; however, standard monitoring variables may fail to detect this deterioration timely. We believe that microcirculation evaluation with standard monitorization with the addition of tissue oxygen saturation monitorization may be of significance for the outcome variables.

Objective: The study was done to determine the effect of different types of drain to postoperative effusion and pain on patients who enderwent coronary artery bypass grafting (CABG).Material and Methods: 50 patients data were evaluated prospectively. Standart drain was placed into 7-8th intercostal area (Group 1). L drain was placed into pleural area (Group 2). Demographic data, drainage amounts were written from hospital documents. Postoperative phericardial and pleural effusion was determined by echocardiography and chest x-ray. Verbal Rating Scale was used to dedicate pain score. Data were analyzed by T test.Results: Groups demographic data were similar. Drainage was 652.0 +/- 328.3 ml (Group 1), 620.0 +/- 169.5 ml (p=0.04) in Group 2. Pain score before taking of drain was 2.0 +/- 2.6 (Group 1), 1.0 +/- 1.6 (p=0.01) in Group 2, after taking of drain was 4.7 +/- 3.0 (Group 1), 2.1 +/- 2.0 (p=0.05) in Group 2. Fifteen day mean phericardial effusion was 0.2 +/- 0.4 cm (Group 1), 0.1 +/- 0.3 (p=0.05) in Group 2. There was no difference between other parameters.Conclusion: Using both types of drain seems to be safe but L drain is more comfortable because of less pain.

Gebode defect, that can accurately be treated surgical repair, is defined as a true communication between left ventricle and right atrium. A 74-year-old woman with a worsening history of ortophnea and peripheral edema was hospitalised. A communication between right atrium and left ventricle was diagnosed using transeusophageal echocardiography. The defect was repaired and mitral valve was replaced with a biologic valve. It would be beter to tailor surgical strategy for each case with atrioventricular canal defect after preoperative transeusophageal echocardiography and peroperative direct sight.

The present study aimed to evaluate the late term changes in radial artery luminal diameter (RAD) and vasodilatation response following transradial coronary intervention (TRI).

Aim: Acute kidney injury after cardiopulmonary bypass has been associated with dilutional anemia during surgery. We aimed both to explore if this relation is modulated by blood transfusion and to understand the postoperative contribution of protein oxidation. Methods: In this randomized prospective study, after ethics committee approval and informed consent, 30 patients undergoing first-time elective coronary artery bypass grafting (CABG) with hematocrit between 21% and 25% at any time during extracorporeal circulation (ECC) were randomly and equally allocated into two groups. Group I consisted of patients who received red blood cells (RBC) during ECC, while in Group II, patients did not receive any RBCs. Besides routine hemodynamic and biochemical parameters, markers of renal injury such as neutrophil gelatinase-associated lipocalin (NGAL), creatinine clearance, and protein oxidation parameters (advanced oxidative protein products [AOPP], total thiol [T-SH]) were determined in both groups. Results: (1) Both cardiovascular parameters (MAP, HR) and the hospitalization period of the transfused group were not significantly different compared to the non-transfused group (P > .05); (2) While urine NGAL level (P < .05) increased and GFR (P < .01) decreased in the transfused group compared to the preoperative period, there were no significant changes in respective parameters of the non-transfused group compared to preoperative period; (3) AOPP concentrations did not change compared to postoperative periods in both groups (P > .05). However, T-SH concentration showed a transient increased at postoperative hour 6 (P < .001 vs preoperative period) but normalized at postoperative hour 24 (P > .05 versus preoperative period). Conclusion: These findings suggest that a hematocrit value over 21% during ECC is safe for renal functions. RBC transfusion just to increase hematocrit may be deleterious.

Background: The inspiratory oxygen fraction (FiO2) is usually set between 60% and 100% during conventional extracorporeal circulation (ECC). However, this strategy causes partial oxygen pressure (PaO2) to reach hyperoxemic levels (>180 mmHg). During anesthetic management of cardiothoracic surgery it is important to keep PaO2 levels between 80-180 mmHg. The aim of this study was to assess whether adjusting FiO2 levels in accordance with body temperature and body surface area (BSA) during ECC is an effective method for maintaining normoxemic PaO2 during cardiac surgery. Methods: After approval from the Ethics Committee of the University of Acıbadem, informed consent was given from 60 patients. FiO2 adjustment strategies applied to the patients in the groups were as follows: FiO2 levels were set as 0.21 × BSA during hypothermia and 0.21 × BSA + 10 during rewarming in Group I; 0.18 × BSA during hypothermia and 0.18 × BSA + 15 during rewarming in Group II; and 0.18 × BSA during hypothermia and variable with body temperature during rewarming in Group III. Arterial blood gas values and hemodynamic parameters were recorded before ECC (T1); at the 10th minute of cross clamp (T2); when the esophageal temperature (OT) reached 34°C (T3); when OT reached 36°C (T4); and just before the cessation of ECC (T5). Results: Mean PaO2 was significantly higher in Group I than in Group II at T2 and T3 (P = .0001 and P = .0001, respectively); in Group I than in Group III at T1 (P = .02); and in Group II than in Group III at T2, T3, and T4 (P = .0001 for all). Conclusion: Adjustment of FiO2 according to BSA rather than keeping it at a constant level is more appropriate for keeping PaO2 between safe level limits. However, since oxygen consumption of cells vary with body temperature, it would be appropriate to set FiO2 levels in concordance with the body temperature in the rewarming period.

Aim: To investigate the relation between use of bone wax and postoperative sternal dehiscence after cardiac surgery.Material and methods: Five thousnad three hundred and eighteen consecutive patients who underwent cardiac surgery between 1999 and 2009 were evaluated prospectively. Perioperative use of bone wax, perioperative data and outcome parameters were recorded. Multivariate logistic regression analysis was performed to define independent risk factors for postoperative sternal dehiscence.Results: Bone wax was used in a total of 1151 (21%) patients. Postoperative sternal dehiscence was detected in 88 (1.6%) patients. The postoperative sternal dehiscence rate was 1.4% in patients without bone wax and 2.5% in patients with bone wax (p = 0.001). The rate of bone wax use was 36.4% in patients with sternal dehiscence and 21.4% in patients without sternal dehiscence (p < 0.001). Independent risk factors for postoperative sternal dehiscence were defined as: age > 70 (OR = 1.9, 95% CI: 1.2-3.1, p = 0.005), chronic obstructive lung disease (OR = 2.4, 95% CI: 1.5-3.9, p < 0.001), use of bone wax (OR = 1.6, 95% CI: 1.03-2.5, p = 0.03), nonelective operation (OR = 2, 95% CI: 1.1-3.4, p = 0.009), and body mass index > 30 (OR = 2.2, 95% CI: 1.4-3.5, p < 0.001).Conclusions: Our findings suggest that use of bone wax may be associated with increased postoperative sternal dehiscence after cardiac surgery. Thus liberal use of bone wax should be restricted.

INTRODUCTION:Clear guidelines for red cell transfusion during cardiac surgery have not yet been established. The current focus on blood conservation during cardiac surgery has increased the urgency to determine the minimum safe hematocrit for these patients. The aim of this study was to determine whether monitoring of cerebral regional oxygen saturation (rSO2) via near-infrared spectrometry (NIRS) is effective for assessing the cerebral effects of severe dilutional anemia during elective coronary arterial bypass graft surgery (CABG). METHODS:The prospective observational study involved patients who underwent cerebral rSO2 monitoring by NIRS during elective isolated first-time CABG: an anemic group (N=15) (minimum Hemoglobin (Hb) <7 g/dL at any period during cardiopulmonary bypass (CPB) and a control group (N=15) (Hb >8 g/dL during CPB). Mean arterial pressure (MAP), pump blood flow, blood lactate level, pCO2, pO2 at five time points and cross-clamp time, extracorporeal circulation time were recorded for each patient. Group results statistically were compared. RESULTS:The anemic group had significantly lower mean preoperative Hb than the control group (10.3 mg/dL versus 14.2 mg/dL; P = .001). The lowest Hb levels were observed in the hypothermic period of CPB in the anemic group. None of the controls exhibited a >20% decrease in cerebral rSO2. Eleven (73.3%) of the anemic patients required an increase in pump blood flow to raise their cerebral rSO2. CONCLUSIONS:In this study, the changes in cerebral rSO2 in the patients with low Hb were within acceptable limits, and this was in concordance with the blood lactate levels and blood-gas analysis. It can be suggested that NIRS monitoring of cerebral rSO2 can assist in decision making related to blood transfusion and dilutional anemia during CPB.

BACKGROUND:Our study evaluated changes in cerebral arterial oxygen saturation (rSO2) during cardiopulmonary bypass (CPB) that were caused by changes in arterial carbon dioxide tension (PaCO2).METHODS:A group of 126 patients undergoing routine, elective, first-time coronary artery bypass graft surgery (CABG) was entered into a prospective study using bilateral near-infrared spectroscopy (NIRS) before anesthetic induction (T1), after anesthetic induction (T2), and continuing at 5-minute intervals during moderate hypothermic (32°C) CPB. Pump flows were set at 2.5 L/min/m(2) and adjusted to maintain mean arterial pressure (MAP) within 10 mmHg of the MAP recorded at the initial fifth minute of CPB (T3). Thirty-two patients were excluded from data collection because MAP could not be stabilized within the target range of 60-90 mmHg. In the remaining 94 patients, after obtaining steady state flow, MAP, and oxygenation, a trial period of hypocarbia (mean PaCO2 of 30 mmHg) was induced by increasing oxygenator fresh gas flow rate (FGFR) to 2.5 L/min/m(2) (T4). A reciprocal period was then measured at reduced FGFR (0.75 L/min/m(2)) (T5).RESULTS:After 20 minutes of a higher (2.75 L/min/m(2)) (FGFR), mean PaCO2 decreased from a baseline of 38 ± 4 mmHg to 30 ± 2 mmHg. This was associated with a parallel decrease (-10 ± 9%) in mixed cerebral oxygen saturation without alteration of mean arterial oxygen tension (PaO2), lactate, MAP, CPB flow, or other parameters implying increased cerebral oxygen extraction.CONCLUSION:Parallel changes in PaCO2 and rSO2 occur during CPB when other variables remain constant, and are due to the effects of carbon dioxide on cerebral arterioles. Cerebral oxygen saturation measured by NIRS may be a useful indirect measure of PaCO2 when continuous blood gas analysis is not possible during open-heart surgery. Cerebral oximetry values may be useful measurements for setting an optimum gas flow rate through the oxygenator.