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Introduction: Previous studies have demonstrated the predictive value of the neutrophil-to-lymphocyte ratio (NLR) in many cardiovascular disorders. The aim of this study was to assess whether NLR is associated with echocardiographic or electrocardiographic parameters, or with predicted five-year risk of sudden cardiac death (SCD), in patients with hypertrophic cardiomyopathy (HCM). Methods: This prospective observational study included 74 controls and 97 HCM patients. Three years of follow-up results for HCM patients were evaluated. Results: NLR was significantly higher in patients with fragmented QRS, ventricular tachycardia, and presyncope than in those without (p=0.031, 0.030, and 0.020, respectively). NLR was significantly higher in patients whose predicted five-year risk of SCD was more than 6% and whose corrected QT interval was greater than 440 ms (p=0.022 and 0.001, respectively). It was also significantly higher in patients whose left ventricular ejection fraction (LVEF) was 60% (p=0.017). Conclusion: NLR was significantly higher in patients with HCM compared to the control group. A high NLR is associated with a higher five-year risk of SCD in patients with HCM. Resumo: Introdução: Estudos prévios demonstraram o valor preditivo da relação neutrófilos/linfócitos (RNL) em muitas alterações cardiovasculares. O objetivo deste estudo foi avaliar se a RNL está associada a parâmetros ecocardiográficos ou eletrocardiográficos, ou com o score de risco de morte súbita cardíaca (MSC) a cinco anos em doentes com miocardiopatia hipertrófica (MCH). Métodos: Este estudo prospetivo observacional incluiu 74 controlos e 97 doentes com MCH. Foram avaliados os resultados dos doentes com MCH ao longo de três anos de seguimento. Resultados: O valor da RNL foi significativamente superior nos doentes com QRS fragmentado, com taquicardia ventricular e com pré-síncope do que nos que não revelaram esses sinais (valores p: 0,031, 0,030, 0,020, respetivamente). O valor RNL foi estatística e significativamente superior nos doentes com risco de MSC previsível a cinco anos superior a 6%, e com um intervalo QT corrigido superior a 440 ms (valores p: 0,022, 0,001, respetivamente). O valor da RNL foi significativamente superior nos doentes com fração de ejeção (FE) 60% (valor p = 0,017). Conclusão: A RNL foi significativamente superior nos doentes com MCH quando comparada com o grupo controlo. Uma RNL alta está associada a um score de risco de MSC elevado aos cinco anos em doentes com MCH. Keywords: Hypertrophic cardiomyopathy, Neutrophil-to-lymphocyte ratio, Five-year risk of sudden cardiac death, Palavras-chave: Miocardiopatia hipertrófica, Relação neutrófilos/linfócitos, Score de risco a cinco anos de morte súbita cardíaca

Optimal hemodynamics in aorta-pulmonary shunt reconstruction is essential for improved post-operative recovery of the newborn congenital heart disease patient. However, prior to in vivo execution, the prediction of post-operative hemodynamics is extremely challenging due to the interplay of multiple confounding physiological factors. It is hypothesized that the post-operative performance of the surgical shunt can be predicted through computational blood flow simulations that consider patient size, shunt configuration, cardiac output and the complex three-dimensional disease anatomy. Utilizing only the routine patient-specific pre-surgery clinical data sets, we demonstrated an intelligent decision-making process for a real patient having pulmonary artery atresia and ventricular septal defect. For this patient, a total of 12 customized candidate shunt configurations are contemplated and reconstructed virtually using a sketch-based computer-aided anatomical editing tool. Candidate shunt configurations are evaluated based on the parameters that are computed from the flow simulations, which include 3D flow complexity, outlet flow splits, shunt patency, coronary perfusion and energy loss. Our results showed that the modified Blalock-Taussig (mBT) shunt has 12% higher right pulmonary artery (RPA) and 40% lower left pulmonary artery (LPA) flow compared to the central shunt configuration. Also, the RPA flow regime is distinct from the LPA, creating an uneven flow split at the pulmonary arteries. For all three shunt sizes, right mBT innominate and central configurations cause higher pulmonary artery (PA) flow and lower coronary artery pressure than right and left mBT subclavian configurations. While there is a trade-off between energy loss, flow split and coronary artery pressure, overall, the mBT shunts provide sufficient PA perfusion with higher coronary artery pressures and could be preferred for similar patients having PA overflow risk. Central shunts would be preferred otherwise particularly for cases with very low PA overflow risk., European Research Council (ERC); European Union; Proof of Concept Grant Kids Surgical Plan; EUFP7; Cardio Fluid Mechanics

Mediastinal fat has been suggested to be associated with cardiovascular diseases such as carotid stiffness, atherosclerosis and coronary artery calcification. We investigated the possible role of Ad-36-induced obesity in the pathogenesis of the coronary artery disease (CAD). Ad-36 DNA was investigated in the anterior mediastinal fat tissue samples of obese adults with CAD. Seventy-five obese adults with left main coronary artery (LMCA) disease, 28 non-obese adults with valvular heart diseases, and 48 healthy individuals without cardiovascular problems were included as the obese patient group (OPG), non-obese patient group (NOG) and healthy control group (HCG), respectively. We also simultaneously investigated Ad-36 antibodies by serum neutralization test (SNA), and measured leptin and adinopectin levels. Ad-36 antibodies were detected only in 10 patients (13.3%) within the 75 OPG. A statistically significant difference was detected between OPG, NOG and HCG in terms of Ad-36 antibody positivity (p0.05). Ad-36 DNA was not detected in mediastinal tissue samples of OPG and NOP without PCR inhibitors. We suggest that Ad-36 may not have an affinity for mediastinal adipose tissue in obese patients with left main CAD and valvular heart diseases. Ad-36 antibody positivity results are not sufficient to reach a causal relationship.

The beneficial effects of the transcatheter aortic valve implantation (TAVI) on echocardiographic parameters including left atrial (LA) and left ventricular (LV) functions were described by previous studies. The aim of this study was to analyze the effects of TAVI on left atrial appendage (LAA) function assessed by transthoracic and transesophageal echocar-diography.Fifty-five patients with severe symptomatic aortic stenosis were included in this prospective study. LAA early and late emptying velocities, LAA filling velocity, peak early diastolic (EM), late diastolic (AM), and systolic (SM) velocities were measured with pulsed wave Doppler and tissue Doppler imaging, and E/Em ratio was calculated before and 7.1 ± 2.8 days after TAVI. A subgroup analysis was performed in accordance with the left ventricular ejection fraction (LVEF) of the patients and the severity of their LV diastolic dysfunction.Although the post-procedure peaks and mean gradients of the patients decreased sig-nificantly, the LVEF increased significantly in those who had low LVEF before the procedure. The post-procedure E/Em ratio decreased significantly (p0.001). The post-procedural LAA mean filling velocity and EM velocity were significantly higher than the pre-procedural filling velocity (p0.001, p = 0.002, respectively). In the subgroup analysis, the post-procedural LAA filling velocity, early and late LAA emptying velocities, in addition to the mean velocity of the EM, AM, and SM were significantly higher than before the procedure in patients with LVEF of50% and E/Em ratios of15.LAA function improved soon after the TAVI procedure, especially in patients with low LVEF and marked LV diastolic dysfunction.

Objective Arterial switch operation has become the treatment of choice for neonates with transposition of the great arteries. The most important step of the procedure is transferring the coronary arteries to the neoaorta successfully. This study shows the impact of coronary anatomy on early mortality and morbidity after arterial switch operation. Methods Ninety-two patients with transposition of the great arteries who underwent arterial switch operation between October 2010 and September 2014 were included in this retrospective study. The patients were classified into two groups: group I (n = 68, patients with usual coronary artery anatomy) and group II (n = 24, patients with unusual coronary artery anatomy). Median age was 10 days (6–25 days) in group I and 14 days (7–29 days) in group II. In group I, 25 patients had ventricular septal defect, nine patients had coarctation of the aorta or distal aortic arch hypoplasia, seven patients had Taussig Bing anomaly. In group II, nine patients had ventricular septal defect, one patient had coarctation of aorta, and one patient had Taussig Bing anomaly. Results Regarding the postoperative variables, no significant statistical difference was found between two groups. But cardiopulmonary bypass time is significantly longer in group II (P = .004). There was no difference in complications including the mortality (P = .265). It is statistically found that associated anomalies did not affect the mortality and complication rates. All mortality cases (n = 4) were related to ventricular dysfunction in group II, whereas only four of the eight patients died because of ventricular dysfunction in group I. Conclusion Coronary artery pattern was not a predictor of mortality in early postoperative period. There may be an impact of unusual coronary artery pattern on the development of ventricular dysfunction as a cause of mortality.

Objective We evaluated autonomic behavior by examining heart rate variability (HRV) in the time domain and frequency domain in pediatric patients who underwent transcatheter closure of atrial septal defect (ASD). Methods A prospective study design was used. Holter ECG was performed in a control group of 30 healthy subjects and a group of 47 patients who underwent transcatheter ASD closure. ECG was taken one day before, one day after, and six months after the procedure to evaluate changes in the time domain [SDNN, rMSSD, NN, pNN50(%), and SDANN] and frequency domain (VLF, LF, HF, VHF, and LF/HF) in the patient group. Student's t-test was used to evaluate changes prior to and after the procedure. Results There were 28 females (60%) in the patient group and 21 females (70%) in the control group. The mean age and weight of the participants in the patient group were 9.61±4.72 years and 32.40±19.60 kg, respectively; the mean age and weight of the control subjects were 10.43±5.31 years and 32.83±13.00 kg, respectively. In both the time domain and frequency domain analyses, the patient group values were found to be lower than those in the control group prior to the procedure; the values in the patient group were found to approach the values in the control group following the procedure. By the sixth month, the values in the patient group reached the control levels with no statistically significant difference (SDNN: 145±0.84, 137.50±42.50; rMSSD: 72.18±48.22, 58.14±28.49; SDANN: 125.13±13.50, 122.40±41.06; VLF: 112.85±29.07, 114.41±98.39; LF: 50.40±24.09, 45.69±15.13; HF: 39.28±19.86, 44.29±13.14; VHF: 10.29±4.24, 9.99±6.47; LF/HF: 1.90±1.44, 1.24±0.81; p>0.05). Conclusion The transcatheter closure of secundum ASDs was found to have a positive effect on HRV. Consequently, it may contribute to reduced mortality and morbidity. We can conclude that in children, HRV recovers approximately six months after transcatheter ASD closure.

Objective: It has been shown that the presence of fragmented QRS (fQRS) is associated with poor prognosis in many cardiovascular diseases and in patients with hypertrophic cardiomyopathy (HCM). However, no study has shown an association with the absolute risk score of sudden cardiac death. The aim of this study was to determine the relationship between QRS and the predicted risk score of sudden cardiac death at 5 years (HCM Risk-SCD) in HCM patients. Methods: In total, 115 consecutive HCM patients were included in this prospective observational study. The patients were divided into two groups according to the presence [fQRS(+) group (n= 65)] or absence [fQRS(-) group (n= 50)] of fQRS on a 12-lead electrocardiogram (ECG). Results: The HCM Risk-SCD (%) HCM Risk-SCD (>6%) values and some echocardiographic parameters, including ventricular extrasystole, ventricular tachycardia, cardiopulmonary resuscitation, implantable cardioverter defibrillator implantation, appropriate shock, and heart failure at the time of admission, were significantly higher in the fQRS(+) group than in the fQRS(-) group (all p4 was identified as an effective cut-off point in fQRS for HCM. An HCM Risk-SCD value of >4 yielded a sensitivity of 77% and a specificity of 76%. Conclusion: fQRS is determined to be an independent high-risk indicator of HCM Risk-SCD. It seems to be associated with increased ventricular arrhythmias and some echocardiographic parameters.

The internal thoracic artery (ITA) is typically harvested from the chest wall by means of conventional electrocautery. We investigated the effects of electrocautery on endothelial-cell and vessel-wall morphology at the ultrastructural level during ITA harvesting. Internal thoracic artery specimens from 20 patients who underwent elective coronary artery bypass grafting were investigated in 2 groups. The ITA grafts were sharply dissected with use of a scalpel and clips in the control group (n=10) and were harvested by means of electrocautery in the study group (n=10). Each sample was evaluated for intimal, elastic-tissue, muscular-layer, and adventitial changes. Free flow was measured intraoperatively. Light microscopic examinations were performed after hematoxylin-eosin and Masson's trichrome staining. Transmission electron microscopy was used to evaluate ultrastructural changes in the endothelial cells and vessel walls of each ITA. In the sharp-dissection group, the endothelial surfaces were lined with normal amounts of original endothelium, endothelial cells were distinctly attached to the basal lamina, cytoplasmic organelles were evident, and intercellular junctional complexes were intact. Conversely, in the electrocautery group, the morphologic integrity of endothelial cells was distorted, with some cell separations and splits, contracted cells, numerous large cytoplasmic vacuoles, and no visible cytoplasmic organelles. The subendothelial layer exhibited disintegration. Free ITA flow was higher in the sharp-dissection group (P=0.04). The integrity of endothelial cells can be better preserved when the ITA is mobilized by means of sharp dissection, rather than solely by electrocautery; we recommend a combined approach.

Cogan's syndrome is a rare idiopathic inflammatory disease with involvement of the eye and inner ear. This syndrome can be associated with aortic root vasculitis. We report the case of a young man with a history of uveitis and bilateral hearing loss who presented with proximal aortic vasculitis and dilatation after aortic valve replacement. Cogan's syndrome was diagnosed on the basis of large artery vasculitis with typical vestibuloauditory and ocular involvement. The patient underwent successful a Bentall operation after aortic valve replacement.

Background The rapid expansion of pediatric cardiovascular surgery, along with the increase in the number of centers and operations, has also increased the use of intraoperative transesophageal echocardiography (TEE). Preoperative TEE allows for the confirmation of diagnoses established by transthoracic echocardiography and angiography, and also identifies possible additional pathologic conditions. TEE is also used to follow up on surgical repairs, determine the need for reintervention, and evaluate myocardial performance and the need for inotropic treatment. Our intention is to share the TEE findings before and after intervention for congenital heart disease in patients who received operations at our center, and the conclusions reached. Patients and Method From October 2009 to February 2013, 1008 patients underwent surgery for congenital heart disease. Of these, 265 were subjected to TEE in the operating room. Each patient entering the operating room with TEE planned had the echocardiography probe placed while intubated under general anesthesia. TEE studies used a GE Vivid S5. Different investigations, according to the patients' particular pathologic conditions, were also performed in addition to standard TEE studies. Results Of the 265 patients for whom surgery was indicated by transthoracic echocardiography and other appropriate examinations, 260 had the diagnosis confirmed by preoperative TEE and the indicated intervention was performed. For the remaining 5 patients (1.8%), the intervention plan was changed following preoperative TEE. Cardiopulmonary bypass was reinitiated in 12 (4.5%) patients because of residual defects identified by postoperative TEE. Thus, the preoperative plan was changed in 17 (6.4%) patients out of a total of 265 owing to preoperative and postoperative TEE findings. Conclusion The use of intraoperative TEE in surgical centers for congenital heart disease allows for a significant reduction in mortality and morbidity. Intraoperative TEE performed by experienced pediatric cardiologists is therefore an absolute necessity.

Coronary sinus atrial septal defect is a rare congenital cardiac anomaly in adults. Patients with this anomaly are generally treated using conventional sternotomy or thoracotomy incisions. However, robotic surgery can be a feasible alternative in this anomaly. We report an adult patient, who presented with coronary sinus atrial septal defect. A totally endoscopic robotic repair was successfully done through a right atriotomy approach in this patient.

Summary– Kabuki syndrome is a rare congenital malformation syndrome characterized by mental retardation, skeletal deformities, auditory dysfunction, cardiac defects, and distinctive facial appearance. Although complex cardiovascular malformations present in early childhood, rarely, atrioventricular septal defects may also present in young adults. Presently described is case of a 22-year-old female with KS who presented with ostium secundum atrial septal defect with deficient rim and idiopathic thrombocytopenic purpura. In this case, minimally invasive robotic surgery was preferred for closure of atrial septal defect.

WOS: 000406051800014, Acute kidney injury (AKI) is associated with cardiovascular mortality and morbidity especially in high-risk patients undergoing cardiac surgery. It ranges from 7.7% to 28.1% in different studies. The aim of this study was to compare cystatin C and neutrophil gelatinase-associated lipocalin (NGAL) with Creatinine as an early marker for acute kidney injury in geriatrics. From 2013 through 2015, 307 consecutive high-risk elderly patients older than 70 years undergoing emergency coronary artery bypass grafting using extracorporeal circulation were studied. All patients underwent diagnostic coronary angiography and the surgical procedure within 1 week in single hospital stay and were randomized according to timing of interval between coronary angiographyand cardiac procedure as follows: group I, less than 2 days; group II, between 2 and 4 days; and group III, higher than 4 days. Renal function was analyzed by serum cystatin C, NGAL, and creatinine. Blood samples were obtained from each patient at five time points: basal value before operation, in the four hours after operation, and on the first, third, and fifth postoperative days. Glomerular filtration rate (GFR) was calculated by Cockcroft-Gault (CG). A total of 56 patients developed postoperative acute kidney failure according to the risk, injury, and failure; and loss; and end-stage kidney disease classification. Perioperative fluid requirements, urine output, and vasopressor need during and after cardiopulmonary bypass were similar. 30-day mortality in groups was higher in group I than group II and group III (P = 0.025). AKI was least prominent in group III compared to group I and group II (P = 0.001) and expectedly, postoperative dialysis requirement was least common in group III (15, 16.66%). Patients in group III had the most favorable clinical outcome with regards to the length of ICU and hospital stay. Overall serum creatinine, cystatin C, and urine NGAL levels changed significantly throughout the entire length of following-up period in group I and group II, but not in group III. Changes in serum levels of cystatin, creatinine, and creatinine clearance were prominent in later than 24 hours. Urinary NGAL was the first variable to rise in the immediate postoperative period. Cystatin GFR was a more rapid marker than serum creatinine GFR to show acute kidney injury in three groups was a significant marker.

Objective: Experience with administration of inhaled nitric oxide (iNO) in pediatric cardiac intensive care unit was retrospectively reviewed. Methods: Data from 32 pediatric patients treated with iNO between 2011 and 2012 were collected. Patients were divided into 3 groups: Group I comprised postoperative patients, Group II comprised newborns with persistent pulmonary hypertension (PPH), and Group III comprised patients with primary pulmonary hypertension (PH) or Eisenmenger's syndrome. Age, sex, weight, primary diagnosis, arterial blood sample, pulmonary artery pressure (PAP), systemic arterial pressure (SAP), and oxygen saturation levels were analyzed. Results: Groups I, II, and III included 25, 3, and 4 patients, respectively. Median weight was 8 kg (range: 3–40 kg), and median age was 7 months (range: 2 days–10 years). On average, iNO treatment was initiated at the 12th hour after admission to the unit (range: 1–48 hours) and continued for a median duration of 24 hours (range: 12–168 hours). Systolic PAP was 40+-15 mmHg, mean SAP was 57+-18 mmHg, PAP/SAP ratio was 0.69, and oxygen saturation levels were 88% prior to iNO treatment. Following iNO treatment, PAP decreased to 24+-9 mmHg (p

Background: This study aims to evaluate early- and midterm outcomes of transcatheter aortic valve implantation.

There is no standard for the selection of technical and mechanical components (heart-lung machine system, oxygenator, arterial and venous cannulae, arterial filter and other specifically-designed components and devices) used in cardiopulmonary bypass in Turkey. The cost of the component plays a significant role in the selection, as well as the preference of the facility. Only a limited number of hospitals decide which components to be used based on scientific data. Studies have confirmed that selected novel techniques and components having no basis of scientific justification may pose risk for the life of the patient in the short- and long-term. The objectives of this study are to show how to use quality-control procedures and scientific data for the selection of novel techniques and components and to share, also, recent techniques experienced to minimize the complication risk after surgery.

Cardiac hemangiomas can occur at any age, but they are extremely rare when they occur early after birth. We describe the case of a 5-month-old infant who had a giant right atrial capillary hemangioma associated with massive pericardial effusion. The tumor was incidentally diagnosed during routine clinical follow-up. The hemangioma was removed successfully under cardiopulmonary bypass, and the patient's postoperative course was uneventful. The occurrence of giant capillary hemangioma in infancy represents an unusual event in the relevant literature. Herein, we discuss the clinical features and surgical management of this rare primary tumor of infancy.

This paper was guest edited by Prof. Per G. Bjornstad, Rikshospitalet –The National Hospital, Paediatric Cardiology, Sognsvannsveien,Oslo, NorwayAims To investigate the effect of stenting and later surgical removal on the architecture and thereforegrowth potential of juvenile vessels.Methods and results Stents were implanted in the carotid artery and jugular vein of six 6-week-oldlambs. Ten weeks later, stents were excised and the vessels closed without the use of patch material.After another 10 weeks, the vessel size (treated and untreated control side) was measured angiographi-cally and the animals terminated for histology. All arteries were patent: treated arterial size was 9+1 mm compared with 11+1 mm on the control side (P ¼ ns). Two veins were completely occludedand two severely stenosed; vessel size was smaller compared with the control side (8+8 vs. 14+5 mm; P ¼ 0.02). Preserved vessel wall integrity was observed in both arteries and veins (except forlocal rupture of the internal elastic lamina with neointimal formation in two arteries leading to mildstenosis).Conclusion Vessel wall architecture remains well preserved after surgical removal of stents implantedin juvenile arteries and veins. However, stenting and subsequent surgical removal results in a high risk ofvenous thrombosis (probably due to the lower blood velocity, lower pressure, and the absence of pulsa-tility in venous vessels).

Atrial fibrillation is the most common rhythm disturbance in clinical practice. It is a major source of stroke and morbidity. Although the Cox maze procedure effectively eliminates atrial fibrillation in most patients, the procedure has not found widespread application. As a consequence, new operations that use alternative sources of energy, such as radiofrequency, microwave, cryothermy, laser, and ultrasound have emerged to surgically create lesion sets to treat atrial fibrillation. This article reviews the fundamentals and current strategies in the surgical treatment of atrial fibrillation.

Arterial switch operation has become the treatment of choice for neonates with transposition of the great arteries. The most important step of the procedure is transferring the coronary arteries to the neoaorta successfully. This study shows the impact of coronary anatomy on early mortality and morbidity after arterial switch operation.Ninety-two patients with transposition of the great arteries who underwent arterial switch operation between October 2010 and September 2014 were included in this retrospective study. The patients were classified into two groups: group I (n = 68, patients with usual coronary artery anatomy) and group II (n = 24, patients with unusual coronary artery anatomy). Median age was 10 days (6-25 days) in group I and 14 days (7-29 days) in group II. In group I, 25 patients had ventricular septal defect, nine patients had coarctation of the aorta or distal aortic arch hypoplasia, seven patients had Taussig Bing anomaly. In group II, nine patients had ventricular septal defect, one patient had coarctation of aorta, and one patient had Taussig Bing anomaly.Regarding the postoperative variables, no significant statistical difference was found between two groups. But cardiopulmonary bypass time is significantly longer in group II (P = .004). There was no difference in complications including the mortality (P = .265). It is statistically found that associated anomalies did not affect the mortality and complication rates. All mortality cases (n = 4) were related to ventricular dysfunction in group II, whereas only four of the eight patients died because of ventricular dysfunction in group I.Coronary artery pattern was not a predictor of mortality in early postoperative period. There may be an impact of unusual coronary artery pattern on the development of ventricular dysfunction as a cause of mortality.

Minimally invasive aortic valve replacement through partial upper sternotomy has been shown to reduce surgical trauma, and, supposedly, decrease postoperative pain, blood loss, and hospital stay.From October 1997 until November 2004, 506 patients received isolated aortic valve replacement, of which 232 underwent the minimal access J-sternotomy approach (group 1). The control group (group 2) consisted of 274 patients who underwent aortic valve replacements by median sternotomy. We retrospectively reviewed outcomes of the patients in the early follow-up period.In group 1 and group 2, respectively, early mortality was 2.6% (6 patients) and 4.4% (12 patients). The minimal access group had reduced aortic cross-clamp and cardiopulmonary bypass times compared with conventional group: 61.8 +/- 16.6 versus 69.5 +/- 16.6 minutes (p0.05) and 88.8 +/- 23.2 versus 100.2 +/- 22.6 minutes (p0.05), respectively. Mean blood loss was lower in group 1 compared with group 2 (p0.05). Intensive care unit and hospital stays were shorter in the minimal access group: 2.1 +/- 2.5 versus 2.5 +/- 5.3 days (p = nonsignificant) and 10.8 +/- 7.1 versus 12.8 +/- 10.6 days (p0.05), respectively.Aortic valve replacement can be performed safely through a partial upper sternotomy on a routine basis for isolated aortic valve disease.

After left internal mammary artery graft is anastomosed to the coronary artery, atherosclerotic occlusion of subclavian artery becomes more important, because the vascular segment between the origin of the subclavian artery and the coronary artery becomes a part of the coronary circulation functionally. The subclavian artery occlusion may be treated through percutaneous intervention including balloon angioplasty alone or with stent. But failure of initial treatment by percutaneous intervention is possible especially in some proximal and total occlusions. In those cases, surgical options include extra anatomic reconstruction, anatomic reconstruction with transthoracic approach or redo-coronary artery surgery in patients with coronary steal syndrome. In this retrospective study, the medical records of 66 patients underwent carotid-subclavian bypass under general or local anesthesia between January, 1990 and January, 2003 were reviewed to analyze the early and long-term results of carotid-subclavian bypass with polytetrafluoroethylene grafts. There were no intraoperative mortalities. There were only one peroperative cerebrovascular accident and one death due to myocardial ischemia early in the post-operative period. Over a mean follow up of 96 months (6 month-144 months), thirteen patients died due to various reasons and there were eleven late graft thrombosis. The primary patency rates at 1, 3, 5 and 10 years were 98%, 91%, 83% and 47%, and the overall survival rates at 1, 3, 5 and 10 years were 100%, 95%, 93% and 38%, respectively. Carotid-subclavian bypass with polytetrafluoroethylene grafts is a safe, effective and durable procedure. It can be easily applied even under regional anesthesia when percutaneous intervention is unsuccessful or impossible.

We present diagnostic echocardiography results of a patient with intracardiac mass who had undergone primary ASD closure and tricuspid valve annuloplasty after being diagnosed with atrial septal defect and tricuspid failure. The atrial mass originated from free right atrial wall junction and tricuspid ring annuloplasty. Typical morphology of intracardiac mass which was considered to be myxoma during preoperative period was found to be an organized thrombus.

We investigated the association between the preoperative logistic clinical syntax score (log CSS), saphenous vein graft (SVG) patency, and major adverse cardiac and cerebrovascular events (MACCEs) after coronary artery bypass surgery (CABG). Of 1875 patients undergoing isolated CABG between 2009 and 2011, 267 patients, who later underwent coronary angiography, were included in the study. The primary end point was at least 1 graft occlusion on the follow-up coronary angiogram. The secondary end point was a composite of MACCE. In multivariate analysis, log CSS was found as a strong predictor of SVG failure (odds ratio [OR] 0.66, 95% confidence interval [CI]: 0.46-0.94, P = .02; and OR: 2.21, 95% CI: 1.02-4.75, P = .04, respectively): log CSS was also associated with MACCE ( P = .001 and P < .001, respectively). The addition of clinical parameters to the anatomical SYNTAX score, termed as “log CSS”, augmented the accuracy and reliability of the prediction of SVG failure and MACCE in patients undergoing CABG.

Translocation of the coronary arteries remains a technical challenge in anatomic correction of transposition of great arteries. Myocardial ischemia related to the difficulties with coronary relocation is an important factor in perioperative and postoperative morbidity and mortality, particularly in the patients with complex coronary artery anatomy. Intramural coronary artery is a rare anatomic variety which may complicate the arterial switch operation in 2% to 4.6% of the reported cases. Even in the hands of experts, the mortality rate may be in twofold in this subset of patients compared with simple transposition of great artery procedures. In this report, 2 successful translocation techniques for intramural coronary arteries in the setting of arterial switch operation are described.

Background Pericardial effusion (PE), atrial fibrillation (AF), and acute kidney injury (AKI) are commonly found after coronary artery surgery. These adverse events may also be interwoven in the postoperative period. In this prospective study, we investigated whether posterior pericardiotomy (PP) with intrapericardial tube positioned along the right atrium (pericardial space intervention) is effective in the prevention of these adverse events. Methods The patients were randomly distributed to the study and control groups. The study group consisted of patients with pericardial space intervention, whereas the control group consisted of patients without pericardial space interventions. In all patients, a straight tube was placed in the anterior mediastinum and an angled tube was placed into the left hemithorax. Results A total of 210 patients were studied: 107 in the control group and 103 in the study group. Statistically significant results were obtained in the amount of PE, cardiac tamponade, AF ( p = 0.019), and AKI during the postoperative period, in favor of the study group. Length of hospital stay was significantly shorter in the study group (6.11 ± 2.31, p = 0.009). Conclusion The PP with intrapericardial tube approach is safe, easy, and effective in the prevention of PE, cardiac tamponade, and AF. The use of this approach may reduce the risk of developing AKI during the postoperative period. Besides, this technique also reduces the length of hospital stay.

The rapid expansion of pediatric cardiovascular surgery, along with the increase in the number of centers and operations, has also increased the use of intraoperative transesophageal echocardiography (TEE). Preoperative TEE allows for the confirmation of diagnoses established by transthoracic echocardiography and angiography, and also identifies possible additional pathologic conditions. TEE is also used to follow up on surgical repairs, determine the need for reintervention, and evaluate myocardial performance and the need for inotropic treatment. Our intention is to share the TEE findings before and after intervention for congenital heart disease in patients who received operations at our center, and the conclusions reached.From October 2009 to February 2013, 1008 patients underwent surgery for congenital heart disease. Of these, 265 were subjected to TEE in the operating room. Each patient entering the operating room with TEE planned had the echocardiography probe placed while intubated under general anesthesia. TEE studies used a GE Vivid S5. Different investigations, according to the patients' particular pathologic conditions, were also performed in addition to standard TEE studies.Of the 265 patients for whom surgery was indicated by transthoracic echocardiography and other appropriate examinations, 260 had the diagnosis confirmed by preoperative TEE and the indicated intervention was performed. For the remaining 5 patients (1.8%), the intervention plan was changed following preoperative TEE. Cardiopulmonary bypass was reinitiated in 12 (4.5%) patients because of residual defects identified by postoperative TEE. Thus, the preoperative plan was changed in 17 (6.4%) patients out of a total of 265 owing to preoperative and postoperative TEE findings.The use of intraoperative TEE in surgical centers for congenital heart disease allows for a significant reduction in mortality and morbidity. Intraoperative TEE performed by experienced pediatric cardiologists is therefore an absolute necessity.

Permanent pacemaker requirement is a known complication after transcatheter aortic valve implantation (TAVI). The aim of the present study was to analyze the effects of Edwards SAPIEN prosthesis implantation on atrioventricular conduction.The study included 28 patients who underwent TAVI due to severe aortic valve stenosis. An electrophysiological study was performed in the catheterization room immediately before the initial balloon valvuloplasty and immediately after Edwards SAPIEN prosthesis implantation.His-ventricle interval was significantly prolonged postprocedure (55.9 ± 11.5 ms) vs preprocedure (47.3 ± 7.8 ms) (P.001). The antegrade Wenckebach point was observed to be significantly prolonged postprocedure (354.4 ± 41.3 ms) vs preprocedure (333.7 ± 45.4 ms) (P=.001). Despite atrial-His interval prolongation, it was not statistically significant. After the procedure, we observed significant conduction disturbances in 3 patients (10.7%). These conduction problems recovered before discharge. One of the patients (3.6%) with right bundle branch block + left anterior fascicular block required permanent pacemaker implantation. At postprocedure electrocardiogram, QRS duration increased, QRS axis shifted to the left, and both of the values became normal before discharge. The patient's echocardiographic and clinical parameters were improved during follow-up.The effect of Edwards SAPIEN on the conduction system was mostly infranodal and temporary. The physical properties of the Edwards SAPIEN prosthesis may explain this observation. This complication may be lessened if the frame height characteristics can be improved.

Rheumatic heart disease is still a major cause of mitral valve dysfunction in developing countries. We present our early results of rheumatic mitral valve repair. From August 2009 through July 2011, 60 patients (24 male and 36 female) with rheumatic disease underwent mitral repair. The mean age was 51.1 ± 13.8 years (range, 16-77 yr). Forty-nine patients were in New York Heart Association functional class III or IV. Repair procedures included chordal and papillary muscle splitting, secondary chordal division, mitral ring annuloplasty (n=58), commissurotomy (n=36), chordal replacement (n=9), posterior leaflet extension (n=4), annular decalcification (n=2), and quadrangular resection (n=2). Secondary procedures included tricuspid ring annuloplasty, left atrial ablation, obliteration of left atrial appendage, aortic valve replacement, and left atrial reduction. The early (30-d) mortality rate was 1.7%. The mean follow-up time was 14.9 ± 5 months (range, 4-26 mo). Follow-up echocardiography revealed trivial or no mitral regurgitation (MR) in 35.5% and mild (1+) MR in 49.1% of patients. Only 1 patient presented with severe (3+) MR. The mean MR grade decreased from 3.2 ± 0.9 to 0.3 ± 0.4 postoperatively (P=0.001). Left ventricular end-diastolic diameter and left atrial diameter significantly decreased postoperatively (P=0.006 and P=0.001, respectively). The mean gradient over the mitral valve decreased significantly from 11 ± 5.9 mmHg to 3.5 ± 1.8 mmHg (P=0.001). Because current techniques of mitral repair can effectively correct valve dysfunction in most patients with rheumatic disease, the number of repair procedures should be increased in developing countries to prevent complications of mechanical valve placement.

Background: Previous studies have demonstrated that platelet activation occurs in patients with aortic stenosis (AS). This study sought to evaluate the changes in hematologic and clinical parameters noted with the improvement in AS following transcatheter aortic valve implantation (TAVI) in patients with severe AS at high risk of surgery. Patients and Methods: The study included 33 patients who underwent TAVI. In addition to biochemical, clinical, and echocardiographic examinations, hematologic blood parameters were recorded before TAVI, at discharge, and at 1 and 4 months. Results: Mean platelet volume (MPV) showed a progressive decrease after TAVI. On echocardiography at 1 month, aortic valve area significantly increased, with significant decreases in peak and mean gradients. Progressive decreases were also noted in N-terminal proB-type natriuretic peptide levels. Conclusion: Our findings show that TAVI improves hemodynamic parameters of the valve with marked clinical and echocardiographic improvement, resulting in decreased platelet activation and MPV in patients with severe AS.

Transcatheter aortic valve implantation (TAVI) is an alternative therapy in patients with severe aortic stenosis (AS) and high surgical risk. Despite continuous improvements in operators' expertise and device technology, complications associated with TAVI are common. We present a case in which an Edwards SAPIEN prosthetic valve dislocated to the left ventricular outflow tract with hemodynamic collapse 4 hours following implantation and embolized into the left ventricle (LV) during resuscitation.