OBJECTIVE:We compared electron microscopic histologic changes of the radial artery grafts in non-diabetic and diabetic patients. METHODS:Thirty-six patients were divided into three groups according to their diabetic status (Group I had no diabetes mellitus [DM], Group II had type two DM and HbA1c levels were <7.5%, and Group III had type 2 DM but HbA1c levels were >7.5%). Distal parts of radial artery grafts were evaluated with scanning electron microscopy in a blind fashion by two histologists. Electron microscopic scores were compared among the groups. RESULTS:Radial artery electron microscopic scores were significantly different between group 1, 2 and 1, 3 and 2, 3 (p = 0.028, p < 0.001, and p < 0.001). In linear regression analysis, duration of DM (p = 0.027) and fasting plasma glucose (p = 0.001) were found as independent risk factors for histologic changes of radial artery grafts. CONCLUSION:Duration of DM and poor glycemic control were found to be associated with radial artery electron microscopic changes. doi: 10.1111/jocs.12761 (J Card Surg 2016;31:410-415).

Background: Increased blood flow may trigger pulmonary arterial wall inflammation, which may influence progression of pulmonary artery hypertension in patients with congenital heart disease. In this study, we aimed to investigate the correlation between preoperative inflammation markers and pulmonary arterial hypertension. Methods: A total of 201 patients with pulmonary hypertension were enrolled in this study retrospectively; they had undergone open heart surgery between January 2012 and December 2013. Patients’ preoperative C-reactive protein (CRP), neutrophil to lymphocyte ratio, red blood cell distribution width, pulmonary pressures, and postoperative outcomes were evaluated. Results: Patient age, neutrophil to lymphocyte ratio, red blood cell distribution width, and CRP were found to be significantly correlated with both preoperative peak and mean pulmonary artery pressures. These data were entered into a linear logistic regression analysis. Patient age, neutrophil to lymphocyte ratio, and CRP were found to be independently correlated with peak pulmonary pressure (P < .001, P < .001, and P = .004) and mean pulmonary artery pressure (P < .001, P < .001, and P = .001), whereas preoperative mean pulmonary artery pressure was found to be independently correlated with intensive care unit stay (P < .001). No parameter was found to be significantly correlated with extubation time and mortality. Eighteen patients had experienced pulmonary hypertensive crisis; in this subgroup, patients’ mean pulmonary artery pressure and neutrophil to lymphocyte ratio were found to be significant (P = .047, P = .003). Conclusion: Preoperative inflammation markers may be correlated with the progression of pulmonary hypertensive disease, but further studies with larger sample size are needed to determine the predictive role of these markers for postoperative outcomes.

Decreased collagen biosynthesis and increased collagenolysis may induce aneurysmal progress in arterial walls. Prolidase plays a role in collagen synthesis. In this study, we sought to evaluate whether there is a correlation between nonatherosclerotic coronary artery aneurysms (CAAs) and prolidase activity. A total of 174 CAAs were diagnosed in 144 (2.1%) patients among 6845 coronary angiographies performed between 2009 and 2012. In all, 23 (15.9%) patients had nonatherosclerotic aneurysms. Prolidase activity was compared to the results of 19 healthy volunteers with normal coronary arteries. Demographic parameters were similar between the groups. Mean prolidase activity was 241.6 ± 54.4 mU/mL in the coronary aneurysm group and 730.3 ± 243.1 mU/mL in the control group ( P < .001). The incidence of CAAs ranges between 0.3% and 5.3% in the general population. Decreased prolidase activity may reduce collagen biosynthesis that may contribute to aneurysm formation.

Objective: Takayasu’s arteritis (TA) is first described by a Japanese ophthalmologist, Mikito Takayasu, in 1908. It is a disease of unknown etiology, primarily affecting aorta and its branches. We present mid-term results of 20 patients who underwent surgery or endovascular intervention due to TA. Material and Methods: Between January 2003 and January 2013, 20 patients with TA underwent surgery or endovascular intervention in our clinic. Their symptoms and findings were upper extremity ischemia (n=10), upper extremity hypertension (n=7), lower extremity claudication (n=5), subclavian steal (n=5), syncope (n=2), vertebro-basillary insufficiency (n=2), and visual disturbances (n=1). Of 20 patients, 13 underwent surgery, 6 underwent endovascular intervention, and 1 underwent a hybrid approach. Results: Restenosis was observed in 6 patients. Aneurysm occurred at right distal anastomotic site of the aorto-bifemoral graft in 1 patient who underwent surgery due to atypical coarctation of the aorta. Transient ischemic attack occurred in 1 patient on 48th day after endovascular intervention to the left carotid artery. There was no mortality in our series. Conclusion: Both surgical and endovascular approaches are commonly used techniques in TA. Restenosis rates of these interventions are similar. Treatment depends on the on the characteristics of the lesion, and the experience of the surgeon.

Ascending aortic dissection and aneurysm are rare but life-threatening complications after aortic valve replacement. Preoperative evaluation of risk factors such as aortic diameter, structural features of aortic wall, and associated diseases may decrease complication rate. We herein present analysis of risk factors of proximal aortic events following aortic valve replacement based on patient with giant dissecting aneurysm who underwent modified Bentall procedure.

We have read the study by Watanabe and colleagues [1Watanabe G. Noda Y. Takagi T. Tomita S. Yamaguchi S. Kiuchi R. Fasudil is a superior vasodilator for the internal thoracic artery in coronary surgery.Ann Thorac Surg. 2013; 96: 543-547Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar] with great interest. The authors present important findings that could improve graft patency and the outcomes of coronary artery bypass grafting. In this study, Fasudil provides a marked vasodilation and an increased graft free flow. We have some questions for the authors. First, how did they determine the sample size? We think that these results could be more impressive and satisfactory with a larger sample size. On the other hand, preprocedural graft free flow was considered relatively low compared with our practice and some previous studies [2Formica F. Ferro O. Brustia M. et al.Effects of papaverine and glycerylnitrate-verapamil solution as topical and intraluminal vasodilators for internal thoracic artery.Ann Thorac Surg. 2006; 81: 120-124Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar]. Were the study groups composed of patients with low graft free flow? As you know, the dose or concentration of papaverine solution is not well established and generally depends on institutional preferences. How did the authors design the composition of papaverine and fasudil solution? Did they consider establishing a dose-dependent relationship between drugs and graft free flow? Biologic in vitro half-life (T1/2) of papaverine is approximately 100 min, but it is less than 30 min for intravenous administration of fasudil [3Gupta V. Gupta N. Shaik I.H. et al.Liposomal fasudil, a rho-kinase inhibitor, for prolonged pulmonary preferential vasodilation in pulmonary arterial hypertension.J Control Release. 2013; 167: 189-199Crossref PubMed Scopus (103) Google Scholar]. Papaverine can prevent graft spasm throughout an operation, but fasudil could not maintain its preventive effect after 30 min. In this sense, the efficacy of oral fasudil against graft spasm may be an interesting topic for investigators. Fasudil increases nitric oxide activity indirectly. We investigated the relationship between nebivolol and perivascular nitric oxide synthase activity and graft free flow. In accordance with the encouraging results of this preliminary study, we replaced our former beta-blocker management with the nebivolol, and we decided to continue this clinical trial. In conclusion, Watanabe's study reveals an encouraging novel therapeutic option in cardiac surgery, but further study is necessary with a larger sample size and comparing different administration methods and doses. Fasudil Is a Superior Vasodilator for the Internal Thoracic Artery in Coronary SurgeryThe Annals of Thoracic SurgeryVol. 96Issue 2PreviewThe internal thoracic artery (ITA) is a very useful conduit for coronary artery bypass artery (CABG), with excellent long-term patency. With the purpose to dilate the ITA graft and increase graft free flow (GFF) intraoperatively, we evaluated the usefulness of intraluminal injection of fasudil, a Rho-kinase inhibitor, in comparison to the conventional graft dilating agent, papaverine. Full-Text PDF ReplyThe Annals of Thoracic SurgeryVol. 97Issue 3PreviewWe thank Drs Gursoy, Hokenek, and Bakuy [1] for their interest in our study that demonstrated the superior vasodilating effect of fasudil on internal thoracic artery (ITA) graft in coronary artery bypass grafting (CABG) [2]. Full-Text PDF

Coronary artery aneurysm is generally presented as an asymptomatic, incidental angiographic finding and often associated with atherosclerosis. In this study we investigated the correlation of inflammation parameters and non-atherosclerotic isolated coronary artery aneurysm.

We read Ugur et al.'s study with interest [1]. Aortic coarctation surgery may be considered a well established procedure in paediatric congenital heart surgery. However, it becomes a complex and challenging procedure in adulthood, especially in the presence of accompanying anomalies. Until the last decade, ascending-descending aortic bypass with a posterior pericardial approach via a sternotomy has been the gold standard for complex coarctation with excellent outcomes [2]. In the era of endovascular interventions, balloon dilatation and stenting have gradually become a reliable option for the management of isolated aortic coarctation [3]. Recently, a hybrid approach has become an alternative technique for treatment of complex cases with encouraging early results [4]. In our institution, we performed ascending-descending aortic bypass as a concomitant procedure in 11 adult patients (9 patients with aortic coarctation and 2 patients with type C interruption of aorta), who had accompanying cardiac diseases. All procedures were done with a median sternotomy and cardiopulmonary bypass in single stage. We performed simultaneous aortic valve replacement, coronary artery bypass grafting, ascending aorta replacement and the Bentall procedure in 4, 3, 2, and 2 patients, respectively. Ascending-descending aortic bypass was done with an anterior aortic approach. The Dacron graft was anastomosed to the lateral ascending aorta and extended toward the left ventricle lateral border. The posterior pericardium was opened and the descending aorta encircled. Descending aorta anastomosis was done with a side clamp. All patients survived surgery without any major adverse cardiac and neurologic events. One patient was reoperated because of infective endocarditis in the second postoperative month. No major adverse cardiac or cerebrovascular events were found in medical follow-up records. The hybrid approach may provide safe and simple repair of coarctation and shortens operative time in patients with accompanying cardiac diseases. Aortic rupture, aneurysmal dilatation, dissection, pseudoaneurysm, restenosis and stent fracture are infrequent but life-threatening complications. Although balloon dilatation and stenting is a well-established treatment in the paediatric population, long-term outcomes and prospective randomized studies comparing surgery and endovascular approaches are necessary in the adult population. Furthermore, extra-anatomic bypass with median sternotomy is a well known technique facilitating the single stage management of concomittant cardiac problems. Limited posterior pericardial incision usually provides adequate exposure for distal anastomosis and decreases the risk of bleeding from excessive collateral vessels. Briefly, we still consider ascending-descending aortic bypass with median sternotomy to be the preferred approach in patients with complex aortic coarctation. Conflict of interest: none declared

INTRODUCTION:The selection of the ideal cannulation site is still one of the major concerns in ascending aortic surgery. In the last decade, many surgeons have chosen to utilize antegrade cerebral perfusion in hypothermic circulatory arrest. In this study, we aimed to evaluate arterial cannulation techniques in patients who underwent root replacement for annuloaortic ectasia.MATERIALS AND METHODS:Between 2005 and 2012, a total of 69 patients with a diagnosis of annuloaortic ectasia underwent aortic root replacement with femoral artery, axillary artery, and direct innominate artery cannulation (IAC). Patients demographic, operative, and postoperative data were collected prospectively and analyzed.RESULTS:A total of 69 patients were investigated. Their ages varied from 13 to 78 (mean age was 54.25 ± 15.69) and 48 patients were male (69.5%). Mean aortic diameter was 5.65 ± 1.58 cm (min: 4.5 cm to max: 7.8 cm) by computerized tomography. The procedures included modified Bentall operation in 61 patients, and Cabrol operation in eight patients. In hospital, the mortality rate was 1.85%, and a 30-day mortality rate was 3.7% in the IAC group and 6.6% in patients who underwent femoral and axillary artery cannulation. Temporary cognitive dysfunction and stroke rate were similar between groups.CONCLUSION:Innominate cannulation is associated with low morbidity and mortality in patients who underwent ascending aorta surgery.

Double aortic arch (DAA) is the most common form of complete vascular ring and results in respiratory and feeding problems because the trachea and the esophagus are circumscribed by the ring. It often occurs as an isolated anomaly; however, DAA may be associated with other congenital cardiovascular anomalies such as the tetralogy of Fallot (TOF), transposition of the great arteries, coarctation of the aorta, ventricular septal defect, and patent ductus arteriosus. [1-3] The coexistence of TOF and DAA is a rare entity. [2,4] We herein present our experience with a patient who was diagnosed with symmetrical DAA in conjunction with TOF along with pulmonary atresia, which resulted in tracheoesophageal compression symptoms. CASE REPORT A six-day-old girl weighing 2.37 kg was referred to our hospital with a diagnosis of pulmonary atresia and TOF. She was intubated immediately after birth due to severe respiratory problems. A physical examination showed the typical findings of TOF, and echocardiography confirmed the diagnosis of TOF with pulmonary atresia. Through a median sternotomy, a shunt was inserted between the right innominate artery and the right pulmonary artery using a 3.5 mm polytetrafluoroethylene (PTFE) graft. An intraoperative evaluation detected the presence of DAA, with both arches being patent and about equal in size. Postoperative multislice computed tomography (MSCT) confirmed the diagnosis of symmetrical DAA. The right subclavian and right common carotid arteries originated from the right aortic arch, whereas the left common carotid and left subclavian arteries originated from the left aortic arch (Figure 1). The trachea and esophagus were circumscribed and compressed by the vascular ring, resulting in tracheal stenosis (Figure 2). In the second operation, a left posterolateral thoracotomy was performed in which the right arch

Background: This study aims to evaluate the effects of pulsatile and non-pulsatile cardiopulmonary bypass techniques on renal functions in elderly.Methods: Between January 2011 and June 2011, 41 patients aged above 70 years who underwent coronary artery bypass grafting (CABG) in our clinic were enrolled in the study. Patients were randomly divided into two groups according to the perfusion technique: pulsatile and non-pulsatile flow. Preoperative, post-cardiopulmonary bypass and at third day following surgery, creatinine, cystatin C, blood urea nitrogen values, urine output during cardiopulmonary bypass and the incidence of acute kidney injury were recorded.Results: At third day following operation, cystatin C, creatinine and blood urea nitrogen values were significantly lower in pulsatile flow group. A significant difference was observed between the groups in terms of urine output during cardiopulmonary bypass and the incidence of acute kidney injury.Conclusion: Pulsatile flow cardiopulmonary bypass is a simple and safe method which may prevent acute kidney injury in elderly.

A severely calcified aorta carries a high risk of atheroemboli and bleeding for cardiac surgery with an incidence range of 14% to 29%. Various techniques were described avoiding cannulation and clamping of the aorta. Nowadays, the no-touch beating heart technique seems to be the best alternative in patients with calcific aorta. Herein, we present a closed proximal anastomosis technique in this high-risk patient group.

Interrupted aortic arch is one of the rarest anomalies among the congenital cardiac defects. Patients must be treated early in life, otherwise death is inevitable. Reports on adult patients with aortic interruption are very rare in the literature. In this report, we present a 21-year-old patient with type A interrupted aortic arch. The patient underwent successful anatomical reconstruction of the descending aorta.

The early patency of arteriovenous fistulas created for hemodialysis is affected by various factors, including venous stenosis. We conducted a study to investigate the effect of venous stenosis on early patency by examining perioperative arterial and venous pressures of the fistula. Among the 15 patients selected for the study, 11 had snuff-box fistulas, 3 Brescia-Cimino, and 1 brachial. A thrill was palpable over the anastomosis in 10 patients and absent in 5 patients. In terms of venous pressure, the patients with a thrill had a mean systolic pressure of 35.8 mm Hg and systolic-diastolic pressure gradient of 3.4 mm Hg. In the patients without a thrill, the values were 102.6 mm Hg and 42.8 mm Hg, respectively. In conclusion, patients with venous obstruction in the fistula had a much higher venous pressure than those with a patent fistula. If venous stenosis is suspected, measurement of fistula pressures may be useful for determining the early patency of arteriovenous fistulas.

Tek ventrikül fizyolojisine sahip iki olguya kardiyopulmoner bypassa girmeden total ekstrakardiyak kavopulmoner anastomoz operasyonu yap›lm›flt›r. Birinci olguya (2.5 yafl›nda) triküspit ve pulmoner atrezi tan›lar› ile modifiye Blalock Taussig flant ameliyat› yap›lm›flt›. Di¤er olguya ise (13 yafl›nda) triküspid atrezisi ve büyük arter transpozisyonu nedeniyle pulmoner bantlama ifllemi uygulanm›flt›. Her iki olguda da bidireksiyonel Glenn anastomozunu takiben s›ras›yla 18 mm ve 22 mm Goretex tüp greft kulln›larak inferior vena kava ile pulmoner arter devaml›l›¤› sa¤land›. Olgular postoperatif erken dönemde ekstübe edildiler. Erken ve orta dönem takiplerinde sorunlar› olmad›.