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BackgroundCoronary artery disease (CAD) is one of the leading causes of mortality and morbidity worldwide. Many patients with CAD require mechanical revascularization. However, restenosis after minimally invasive intervention is a major problem for these patients. Fortunately, due to the controlled drug delivery properties of drug-eluting stents (DES), this problem seems to be significantly overcome. In this study, the pharmacodynamic and pharmacokinetic properties of Atlas sirolimus-eluting coronary stents coated with PLGA were evaluated.Materials and MethodsThis study was carried out in 20 non-atherosclerotic female sheep, divided into four groups that included 4 study and 1 control randomly assigned to each group. The animals in the study groups were stented with Atlas Drug-eluting coronary stents and the pharmacodynamic and pharmacokinetic properties were evaluated.ResultsA statistically important effectivity of sirolimus on the vascular endothelium was shown. With time, the decrease in sirolimus in blood samples was statistically significant. In the others, no clinically significant side effects were observed.ConclusionsThe results in this study showed a significant reduction in neointimal hyperplasia after experimental implantation of Atlas drug-eluting stents coated with PLGA polymer. Pharmacokinetic studies also showed that the stent did not release significant left sirolimus after 28 days.

Background/aim: Left ventricular hypertrophy (LVH) involves increased muscular mass of the left ventricle due to increased cardiomyocyte size and is caused by cardiomyopathies. Several microRNAs (miRNAs) have been implicated in processes that contribute to heart disease. This study aimed to examine miRNA-133, miRNA-26 and miRNA-378 as candidate biomarkers to define prognosis in patients with LVH. Patients and methods: The study group consisted of 70 patients who were diagnosed with LVH and 16 unaffected individuals who served as the control group. Real-time polymerase chain reaction (RT-PCR) was used to analyze serum miRNA-133, miRNA-26, and miRNA-378 expression levels in LVH patients and the control group. Receiver operating characteristic (ROC) curve analysis was performed to assess the diagnostic capability of miRNA-378. Results: When crossing threshold (CT) values were compared between patient and control samples, we found that there were no statistically significant differences in miRNA-133 and miRNA-26 CT values, while the miRNA-378 expression was significantly increased in LVH patients. ROC analysis demonstrated that the expression levels of miRNA-378 (AUC=0.484, p=0.0013) were significantly different between groups. Conclusion: We observed a statistically significant relationship between miRNA-378 expression levels and LVH, suggesting that circulating miRNA-378 may be used as a novel biomarker to distinguish patients who have LVH from those who do not. No sponsor

Background A significant proportion of patients presenting for isolated aortic valve replacement (AVR) demonstrate some degree of functional mitral regurgitation (fMR). Guidelines addressing concomitant mitral valve intervention in those patients with moderate fMR lack strong evidence-based support. Our aim is to determine the effect of untreated moderate fMR at the time of AVR on long-term survival. Methods All patients undergoing isolated AVR from 2000 to 2013 at our institution were retrospectively reviewed. Patients were stratified according to severity of preoperative fMR; 0–1+ MR (Group NoMR, n = 1826) and 2–3+ MR (Group MR, n = 330). All patients in Group MR were propensity-matched with patients in Group NoMR to control for differences in baseline characteristics. The primary outcome of interest was overall survival. Results Propensity analysis matched 330 patients from each group. Mean age was 77.9 ± 10.0 years and 50.6% were male. There were no differences in baseline demographics, echocardiographic parameters, or co-morbidities between groups. Kaplan-Meier analysis showed significantly worse medium and long-term survival in Group MR compared to Group NoMR (log-rank p = 0.02). Follow-up echocardiography showed slightly more severe MR in Group MR (1.1 ± 0.7 MR vs. 0.8 ± 0.7 NoMR, p = 0.03) at 1 year. Conclusions Patients undergoing isolated AVR with concomitant 2–3+ fMR experience poorer long-term survival than those patients with no or mild fMR. This suggests that mitral valve intervention may be necessary in patients undergoing AVR with clinically significant fMR.

Objectives: Del Nido cardioplegia in adult cardiac surgery has not been studied although it has been in common use as a “single” dose cardioplegia in pediatric heart surgery. We retrospectively assessed the short-term (in-hospital) clinical outcomes of patients undergoing aortic valve replacement (AVR) using del Nido cardioplegia solution, comparing it to conventional multi-dose whole blood cardioplegia. Methods: We switched our cardioplegia protocol from conventional whole blood cardioplegia exclusively to del Nido solution in May 2011. In 2011, 240 consecutive patients underwent isolated AVR. One hundred and seventy-eight of them were operated on with the use of del Nido cardioplegia (del Nido group) and whole blood cardioplegia (conventional group) was used in the other 62 patients. Isolated AVR was chosen as a cohort because of its relative simplicity and the similarity of surgical techniques among surgeons. Propensity-score matching identified 54 matched pairs for analysis. Results: The retrograde cardioplegia technique was used in 19 cases (35.2%) in the del Nido group and 52 cases (96.3%) in the conventional group (pConclusions: Short-term outcomes in adult cardiac surgery using del Nido solution were acceptable and comparable to conventional multi-dose whole blood cardioplegia. The del Nido cardioplegia technique was associated with shortened cross-clamp times and less frequent utilization of the retrograde cardioplegia delivery technique.

OBJECTIVES: Chronic kidney disease (CKD) is prevalent in patients undergoing aortic valve replacement (AVR). We sought to evaluate the impact of AVR on estimated glomerular filtration rate (eGFR) levels and determine the impact of reversibility of CKD on postoperative outcomes. METHODS: We retrospectively reviewed 2169 patients who underwent isolated AVR between 2000 and 2012. eGFR was calculated using the CKD-EPI formula. Based on preoperative eGFR, patients were divided into three groups: NoCKD (eGFR >60, n= 1417), ModCKD (eGFR = 30–60, n= 619) and SevCKD (eGFR = 15–30, n= 86). End-stage renal disease patients (eGFR

Background Acute kidney injury (AKI) is a significant complication of surgical aortic valve replacement (SAVR). This study sought to describe AKI following SAVR, its risk factors, predictors and effect on long-term survival. Methods We retrospectively reviewed 2169 patients who underwent isolated SAVR between 2000 and 2012. The main end-points were occurrence of AKI, postoperative complications, and short- and long-term survival rates following SAVR. Patients were divided into two groups: AKI+ (n = 181) and AKI− (n = 1945). Results AKI occurred in 8.5% of patients, of which 3.9% (n = 7) needed dialysis. Predictors of AKI after SAVR were body mass index (BMI) and intraoperative packed red blood cells (PRBC) transfusion. AKI+ patients had a more complicated postoperative course and higher cumulative mortality (25% vs. 17%, p = 0.012) with a median follow-up of 4.1 years. AKI was not found to be an independent predictor of mortality. Conclusions Predictors of AKI after SAVR are increased BMI and intraoperative PRBC transfusion. AKI conferred an increase in hospital length of stay and cumulative mortality while the need for postoperative dialysis was associated with the most complicated hospital stays and the highest in-hospital and cumulative mortalities; therefore careful recognition of patients at risk of AKI is warranted for a better preoperative renal optimization. However, incidence of AKI was lower than what is reported after both on-CPB cardiac surgeries and transcatheter aortic valve replacement, moreover AKI was not found to be an independent predictor of mortality. doi: 10.1111/jocs.12586 (J Card Surg 2015;30:631–639)

Induction therapy with interleukin-2 receptor antagonists has been established as an effective immunosuppressive strategy in the management of heart transplant (HTx) recipients. We compared outcomes following HTx in patients receiving basiliximab, daclizumab, or no induction therapy.We investigated post-transplant prognosis of patients receiving basiliximab (n=67), daclizumab (n=98) or no induction therapy (n=70). Patients treated with daclizumab (50.3 ± 14.7 years) were younger than those receiving basiliximab (55.8 ± 11.2 years) or no induction therapy (54.9 ± 14.1 years; both P0.05). Patients receiving either induction therapy showed better survival 1 year after HTx (95%) than those without induction therapy (82%; P0.001). Survival was similar between patients receiving basiliximab and daclizumab. The incidence of acute cellular or antibody-mediated rejections did not differ among the groups. The main reason that patients did not receive induction therapy was ongoing infection (65.7%), which was more common in patients on ventricular assist device (VAD) support than those without VAD (76.1% vs. 45.8%; P=0.004). The VAD-related infection rate in the entire study cohort was 29.7% (35/118 VAD recipients).Survival following HTx was worse in patients not receiving induction therapy. No differences were noted in survival or the incidence of rejection between the daclizumab- and basiliximab-treated groups. Induction therapy was less used in patients with infection, which was related to prior VAD support.

Background: Endovenous thermal ablation of the small saphenous vein carries a risk for sural nerve injury. Ablation above mid-calf level is recommended to avoid it. However, this strategy could not eradicate this complication. We present our results of consecutive 30 small saphenous vein thermal ablations which are performed after ultrasonographic identification of the sural nerve. Methods: We studied 26 consecutive subjects with a total of 30 limbs. Ablation was performed proximal to the risk point by a 1470-nm diode laser. Patients were asked to attend follow-up outpatient controls at 7 days, 30 days, and 180 days postoperatively. Rate of identification of the sural nerve by ultrasonography, safety of the mid-calf level as a puncture site and postoperative sural nerve damage were assessed. Results: The sural nerve identification was achieved by ultrasonography in all patients except for one. Mid-calf level as a puncture site was not safe in three (10%) extremities. None of the patients showed any evidence suggesting postoperative sural nerve damage. Conclusion: Choosing the puncture site according to the risk point may be more reasonable than general mid-calf level which is being used.

Background. The aim of the study is to compare the current two endovenous thermal ablation methods by examining the effects on the visual analog scale (VAS) and the short form-36® quality of life index. Methods. Ninety-six patients who underwent unilateral endovenous thermal ablation of great saphenous vein were included. ClosureFast™ catheters were used in the RFA group and 1470 nm radial fiber laser catheters were used in the EVLA group. Results. The RFA group consisted of 41 patients and the EVLA group consisted of 55 patients. The preoperative baseline characteristics of both groups were similar. On the day of operation, VAS values were 2.8±1.1 in the RFA group and 3.6±1.8 in the EVLA group (p=0.02). Comparisons of short form-36 parameters in both groups showed them to be similar except the pain detected at postoperative 1st week (48.1±5.4 for RFA, 44.9±7.6 for EVLA, p=0.04). Conclusion. Results in postprocedural quality of life were found to be similar in both of the techniques. However, in terms of postoperative pain, radiofrequency ablation is still superior to the 1470 nm radial fiber laser catheters.

Background and Aims The immediate postischemic period is marked by elevated intracellular calcium levels, which can lead to irreversible myocyte injury. Del Nido cardioplegia was developed for use in the pediatric population to address the inability of immature myocardium to tolerate high levels of intracellular calcium following cardiac surgery. Our aim in this study is to determine if this solution can be used safely and effectively in an adult, reoperative population. Methods All patients undergoing isolated reoperative aortic valve replacement at our institution from 2010 to 2012 were retrospectively reviewed. Demographics, comorbidities, operative variables, postoperative complications, and patient outcomes were collected. Patients were divided into two groups based on cardioplegia strategy used: whole blood cardioplegia (WB, n = 61) and del Nido cardioplegia (DN, n = 52). Results Mean age in the study was 73.4 ± 14.3 years and 86 patients were male (76.1%). Eighty-four patients had undergone prior coronary artery bypass graft (CABG) (74.3%). Patients in the DN group required significantly lower total volume of cardioplegia (1147.6 ± 447.2 mL DN vs. 1985.4 ± 691.1 mL WB, p

A percentage of patients with a left ventricular assist device (LVAD) require device exchange. Although this is an important clinical entity, there are only a handful of relevant studies on this topic in the literature.From 2004 to 2012, 30 device exchanges (HeartMate II to HeartMate II) were performed. Since June 2011, we have employed the subcostal approach for device exchange if indicated. Sixteen patients underwent device exchange through a subcostal approach (S group), whereas 14 patients had devices exchanged through a full sternotomy (F group). Pre- and post-operative data were retrospectively reviewed.There was no difference in baseline patient characteristics between the two groups. Overall, mean duration between primary surgery and device exchange was 425 ± 407 days. Surgical indications included device thrombus/hemolysis (N = 19), device malfunction (N = 9) and infection (N = 2). Cardiopulmonary bypass time was significantly shorter in the S group (S: 40 ± 23 minutes, F: 105 ± 84 minutes; p0.05), and post-operative bleeding within 24 hours after surgery was less in the S group (S: 362 ± 367 ml, F: 1,286 ± 971 ml; p0.05). Length of ICU stay was significantly shorter in the S group (S: 4.6 ± 1.8 days, F: 8.2 ± 4.9 days; p0.05). There was no difference in post-operative complications, except for prolonged intubation (F: N = 6 [43%], S: N = 1 [6.3%]; p0.05). There were 3 deaths in the F group and 0 in the S group, with no statistical difference (p = 0.09). Also, there was no significant difference in other outcomes, including transplantation, device explantation and ongoing LVAD support.A subcostal approach may be preferred for HeartMate II device exchange if indicated.

Background Del Nido (DN) cardioplegia, a calcium-free, hyperkalemic solution containing lidocaine and magnesium has been developed to help reduce intracellular calcium influx and the resulting myocyte damage in the immediate postischemic period following cardiac arrest. DN cardioplegia has been used for pediatric cardiac surgery but its use in complex reoperative surgery has not been studied. We specifically report the outcomes of patients undergoing reoperative cardiac surgery after previous coronary artery bypass grafting with a patent internal mammary artery (IMA). Methods Patients undergoing reoperative cardiac surgery with prior coronary bypass grafting surgery were studied between 2010 and 2013. Fourteen patients were identified who required continued retrograde cardioplegia administration. In all cases, an initial antegrade dose was given, followed by continuous retrograde administration. Demographics, co-morbidities, intra-operative variables including cardioplegia volumes, post-operative complications, and patient outcomes were collected. Results The mean age of all patients was 73.3+/−6.7 years, and 93 % were male. Aortic cross clamp time and cardiopulmonary bypass times were 81+/−35 and 151+/−79 mins, respectively. Antegrade, retrograde and total cardioplegia doses were 1101+/−398, 3096+/−3185 and 4367+/−3751 ml, respectively. An average of 0.93+/−0.92 inotropes and 1.50+/−0.76 pressors were used on ICU admission after surgery. ICU and total hospital lengths of stay were 5.5+/−7.4 and 9.6+/−8.0 days, respectively. Complications occurred in two patients (14 %) (pneumonia and prolonged mechanical ventilation) and new arrhythmias occurred in five patients (36 %) (four new-onset atrial fibrillation and one pulseless electrical activity requiring 2 min of chest compression). No perioperative myocardial infarctions were noted based on electrocardiograms and cardiac serum markers. Postoperatively, left ventricular function was preserved in all patients whereas two patients (14 %) had mild decrease in right ventricular function as assessed by echocardiography. No mortality was observed. Conclusion Del Nido cardioplegia solution provides acceptable myocardial protection for cardiac surgery that requires continuous retrograde cardioplegia administration. DN cardioplegia’s administration in a continuous retrograde fashion with a patent IMA is believed to provide adequate myocardial protection while avoiding injuring the IMA through dissection and clamping.

Abnormal intracellular calcium (Ca2+) handling can trigger endoplasmic reticulum (ER) stress, leading to activation of the unfolded protein response (UPR) in an attempt to prevent cell death. Mechanical unloading with a left ventricular assist device (LVAD) relieves pressure-volume overload and promotes reverse remodeling of the failing myocardium. We hypothesized that mechanical unloading would alter the UPR in patients with advanced heart failure (HF). UPR was analyzed in paired myocardial tissue from 10 patients with dilated cardiomyopathy obtained during LVAD implantation and explantation. Samples from healthy hearts served as controls. Markers of UPR [binding immunoglobulin protein (BiP), phosphorylated (P-) eukaryotic initiation factor (eIF2α), and X-box binding protein (XBP1)] were significantly increased in HF, whereas LVAD support significantly decreased BiP, P-eIF2α, and XBP1s levels. Apoptosis as reflected by C/EBP homologous protein and DNA damage were also significantly reduced after LVAD support. Improvement in left ventricular dimensions positively correlated with P-eIF2α/eIF2α and apoptosis level recovery. Furthermore, significant dysregulation of calcium-handling proteins [P-ryanodine receptor, Ca2+ storing protein calsequestrin, Na+-Ca2+ exchanger, sarcoendoplasmic reticulum Ca2+-ATPase (SERCA2a), ER chaperone protein calreticulin] was normalized after LVAD support. Reduced ER Ca2+ content as a causative mechanism for UPR was confirmed using AC16 cells treated with a calcium ionophore (A23187) and SERCA2a inhibitor (thapsigargin). UPR activation and apoptosis are reduced after mechanical unloading, which may be mediated by the improvement of Ca2+ handling in patients with advanced HF. These changes may impact the potential for myocardial recovery.

Background: Staphylococcus aureus remains a leading cause of IE, but it is unknown whether S. aureus is associated with more severe infections or worsened outcomes compared to other bacterial organisms. The primary purpose of this study was to compare the clinical characteristics and mortality in S. aureus (SA) versus non-S. aureus (NSA) IE patients undergoing valvular surgery. Methods: All patients undergoing valvular surgery for bacterial IE between 1995 and 2013 at our institution were included in this study. Clinical data were retrospectively collected from chart review. Patients were categorized according to causative organism: 1) SA: n=85, and 2) NSA: n=238, composed of coagulase-negative staphylococci (23%), streptococci (12% viridans; 19% non-viridans), enterococci (17%), and other (51%). Results: SA patients had a higher severity of illness compared to NSA patients due to higher rates of preoperative vascular complications (58.8% vs. 39.4%, p = 0.002), preoperative septic shock (23.5% vs. 13.9%, p = 0.039), preoperative embolic events (33.3% vs. 20.7%, p = 0.02), preoperative stroke (27.1% vs. 13.5%, p = 0.004), and annular abscess (44.7% vs. 27.3%, p = 0.003). There were no statistically significant differences in 30-day (9.4% vs. 8.0%, p = 0.68, OR = 1.20) or 1-year (20% vs. 14.3%, p = 0.22, OR = 1.50) post-operative mortality between SA and NSA IE patients, respectively. However, length of hospital stay, and 30-day post-operative development of new renal failure were higher in SA patients. There was a trend to more post-operative embolic events in SA patients. Conclusions: SA IE is associated with higher morbidity on presentation, such as pre-operative embolic events, stroke and annular abscess, compared to IE caused by other bacterial organisms, but does not lead to increased mortality after surgery. Further research is needed to investigate the differences in post-operative complications among patients.

Background: Ca2+/calmodulin-dependent protein kinase (CaMK)II has been implicated in impaired myocardial Ca2+ signaling and may play an important role in the development of heart failure (HF). The objective of this study was to characterize CAMKII signaling in patients with HF before and after prolonged left ventricular assist device (LVAD) support. Methods: LV apex tissue pairs were collected in patients with dilated cardiomyopathy (n=10) at LVAD implantation and explantation. Normal cardiac tissue was used as control (n=4). Total protein, as well as cytoplasmic and nuclear fractions, were analyzed by Western Blot analysis. Results: The duration of LVAD support ranged from 48 to 595 days (mean = 271±54) with no patient exhibiting myocardial recovery. Total CamKIIδ levels in failing hearts were significantly higher than normal hearts and increased after LVAD, mainly due to an increase in cytoplasmic CaMKIIδC, which regulates Ca2+ handling (Table 1). Nuclear CaMKIIδB, which regulates Ca2+ gene transcription, did not change. Calmodulin remained increased in the nuclear and cytoplasmic fractions after LVAD. CaMKII autonomous, non-CaM-dependent activity, reflected by phosphorylation in Thr207, was increased pre- and post LVAD in cytoplasmic CaMKIIδC. The CaMKII-dependent myocyte enhancer factor 2 (MEF2) was increased pre- and significantly further post LVAD in the nucleus while decreased in the cytoplasm, suggesting translocation into the nucleus after LVAD support. Class IIa HDACs 4 and 5 interact with MEF2, resulting in repression of MEF2-dependent genes. Phosphorylated levels of HDAC4 and HDAC5 were increased pre- and post LVAD, which would result in activated MEF2. Conclusions: This study shows for the first time an increase of the hypertrophic factor MEF2 associated with persistent activation of CamKIIδC after prolonged LVAD support, which may have implications for cardiac remodeling during mechanical support.

Background Repair of complete atrioventricular canal early in infancy has traditionally carried greater morbidity and mortality than repair performed later. However, an individualized anatomy-based repair may give young infants outcomes that are equivalent to older patients. Methods We retrospectively reviewed 139 patients who underwent complete atrioventricular canal repair from January 2005 to December 2012. An individualized approach was used: 2-patch repair was performed in 98 patients for large ventricular septal defects and a modified single-patch ("Australian technique") was used in 41 for "shallow" ventricular septal defects. Results The average age was 25.5 ± 3.9 weeks, 50% were boys, and 78% had trisomy 21. Mean follow-up was 5.1 ± 0.2 years, with 100% completeness of data. There were 3 in-hospital deaths (2.1%) and 1 late death (0.7%). A permanent pacemaker was required in 2 patients (1.4%). The rate for left atrioventricular valve reoperation was 8% at a mean of 211 ± 238 days after the original repair (range, 6 to 682 days). Compared with patients aged older than 3 months, the 39 patients (28%) who were younger than 3 months had similar perioperative courses and rate of reoperation. Compared with patients with an Australian repair, the 98 patients (71%) with a 2-patch repair were more likely to have trisomy 21 and had slightly increased cardiopulmonary bypass and cross-clamp times but similar outcomes. Multivariate analysis showed postoperative left atrioventricular valve regurgitation greater than 2 and left ventricular outflow tract obstruction were significant risk factors for reoperation on the left atrioventricular valve (both p Conclusions Repair of complete atrioventricular canal using an individualized surgical approach yields reoperation and early mortality rates similar for younger infants compared with older infants, obviating the need to delay operation in symptomatic patients.

Objective Del Nido (DN) cardioplegia solution provides a depolarized hyperkalemic arrest lasting up to 60 minutes, and the addition of lidocaine may limit intracellular calcium influx. Single-dose DN cardioplegia solution may offer an alternative myocardial protection strategy to multi-dose cold whole blood (WB) cardioplegia following acute myocardial infarction (AMI). Methods We retrospectively reviewed 88 consecutive patients with AMI undergoing coronary artery bypass (CABG) surgery with cardioplegic arrest between June 2010 to June 2012. Patients exclusively received WB (n = 40, June 2010-July 2011) or DN (n = 48, August 2011-June 2012) cardioplegia. Preoperative and postoperative data were retrospectively reviewed and compared using propensity scoring. Results No significant difference in age, maximum preoperative serum troponin level, ejection fraction, and STS score was present between DN and WB. A single cardioplegia dose was given in 41 DN vs. 0 WB patients (p < 0.001), and retrograde cardioplegia was used 10 DN vs. 31 WB patients (p < 0.001). Mean cardiopulmonary bypass and cross clamp times were significantly shorter in the DN group versus WB group. Tranfusion rate, length of stay, intra-aortic balloon pump requirement, post-operative inotropic support, and 30-day mortality was no different between groups. One patient in the WB group required a mechanical support due to profound cardiogenic shock. Conclusions DN cardioplegia may provide equivalent myocardial protection to existing cardioplegia without negative inotropic effects in the setting of acute myocardial infarction. Electronic supplementary material The online version of this article (doi:10.1186/s13019-014-0141-5) contains supplementary material, which is available to authorized users.

Background. Hybrid percutaneous coronary intervention offers an alternative method of revascularization for high-risk surgical populations. We report the outcomes of a single-stage hybrid strategy in valvular cardiac surgery and explore its effects on operative risk and bleeding. Methods. In a hybrid operating room, 26 patients underwent hybrid surgery consisting of femoral arterial access, then coronary stenting followed by valve surgery, with appropriate heparin dosing. Clopidogrel (300 mg) was given on anesthesia induction in nonreoperative cases, or at the time of cross clamping (after stenting) for reoperative cases. Results. Mean follow-up was 680 ± 277 days. The planned coronary stenting and surgery was successful in all patients. Major cardiovascular and cerebrovascular adverse events occurred in 1 patient, with no inhospital deaths observed. No vascular complication or stent thrombosis was observed with the described antiplatelet regimen. Outcomes were comparable to those of standard bypass valve replacement surgery. Conclusions. This study demonstrates the feasibility and early safety of a single-stage hybrid strategy with coronary stenting followed by valvular surgery in patients at increased surgical risk. Hybrid procedures may lower operative risk by eliminating or reducing the need for bypass grafting.

Occlusion of a coronary artery by an acute type A aortic dissection presents a life-threatening emergency that is rarely seen and easy to misdiagnose. We present the case of a 75-year-old male who experienced sudden onset of severe left-sided chest pain due to an acute type A aortic dissection that obstructed the right coronary artery. Following an initial misdiagnosis of acute coronary syndrome, imaging revealed the presence of an aortic dissection. An emergency modified Bentall procedure was performed, in which the damaged aorta and aortic valve were replaced.

Background There are currently no well-defined, evidence-based guidelines for management of end-stage heart failure in patients over 65, and the decisions to use mechanical circulatory support with left ventricular assist device (LVAD), either as a bridge to transplantation or destination therapy, or isolated heart transplantation (HTx) remain controversial. We aimed to compare the outcomes after the implementation of three heart replacement strategies in this high-risk population. Methods We conducted a retrospective cohort study of all patients between the ages of 65 and 72 receiving a continuous-flow LVAD as bridge to transplantation or destination therapy or isolated HTx at our center between 2005 and 2012. The patients were stratified according to treatment strategy into three groups: group D (destination LVAD, n = 23), group B (bridge to transplantation LVAD, n = 43), and group H (HTx alone, n = 47). The primary outcomes of interest were survival to discharge and 2-year overall survival. Results The patients in group D were significantly older, had a higher prevalence of ischemic cardiomyopathy, and had a higher pulmonary vascular resistance than did patients in groups B or H. There were no significant differences between groups in survival to discharge (87% D vs 83.7% B vs 87.2% H, p = 0.88) or 2-year overall survival (75.7% D vs 68.7% B vs 80.9% H, log-rank p = 0.47). The incidence rates of readmission were 1.1 events/patient·year in group D and 0.5 events/patient·year in group H. Conclusions There was no significant difference in perioperative, short-term, and medium-term survival between the treatment groups. However, the LVAD patients had a higher incidence of readmission. Larger trials are needed to refine differences in long-term survival, quality of life, and resource utilization for elderly patients requiring heart replacement therapy.

The immediate postischemic period is marked by elevated intracellular calcium levels, which can lead to irreversible myocyte injury. Del Nido cardioplegia was developed for use in the pediatric population to address the inability of immature myocardium to tolerate high levels of intracellular calcium following cardiac surgery. Our aim in this study is to determine if this solution can be used safely and effectively in an adult, reoperative population.All patients undergoing isolated reoperative aortic valve replacement at our institution from 2010 to 2012 were retrospectively reviewed. Demographics, comorbidities, operative variables, postoperative complications, and patient outcomes were collected. Patients were divided into two groups based on cardioplegia strategy used: whole blood cardioplegia (WB, n = 61) and del Nido cardioplegia (DN, n = 52).Mean age in the study was 73.4 ± 14.3 years and 86 patients were male (76.1%). Eighty-four patients had undergone prior coronary artery bypass graft (CABG) (74.3%). Patients in the DN group required significantly lower total volume of cardioplegia (1147.6 ± 447.2 mL DN vs. 1985.4 ± 691.1 mL WB, p 0.001) and retrograde cardioplegia dose (279.3 ± 445.1 mL DN vs. 1341.2 ± 690.8 mL WB, p 0.001). There were no differences in cross-clamp time, bypass time, postoperative complication rate, or patient outcomes between groups.Del Nido cardioplegia use in an adult, reoperative aortic valve population offers equivalent postoperative outcomes when compared with whole blood cardioplegia. In addition, use of del Nido solution requires lower total and retrograde cardioplegia volumes in order to achieve adequate myocardial protection.

Myostatin (MSTN), a negative regulator of muscle growth, is induced by cardiac overload and may regulate the transition from physiologic hypertrophy to ventricular dilatation. We hypothesized that patients with severe aortic stenosis (AS) and hypertrophic cardiomyopathy (HCM) have distinctive anti

We sought to evaluate the incidence, predictors, and outcomes of acute kidney injury (AKI) in patients undergoing aortic valve replacement (AVR). We retrospectively reviewed 1667 consecutive patients who underwent AVR between 2000-2012. Patient demographic, clinical, and survival were analyzed. AKI

Patients with high-risk coronary lesions such as left main stenosis and a severely depressed left ventricular ejection fraction are at risk of death and morbidity-related complications during coronary artery bypass surgery. Several alternative methods have been developed for managing this problem, but it is still challenging, even for highly experienced and well-equipped cardiac surgery centers. We report the case of a successful coronary artery bypass surgery supported by the Impella® Recover LP 2.5 assist device and using an alternative insertion technique for the ascending aorta in a patient with high-risk coronary lesions, such as left main disease.

Bronchogenic cysts that formed during the development of the tracheobronchial tree in the gestational period are mostly asymptomatic until adulthood. Cysts localized in the middle mediastinum, specifically in the subcarinal region, on the other hand, may cause serious symptoms by compressing the heart and major vessels due to their close proximity. In this report it is suggested that surgical resection of a giant bronchogenic cyst that compresses the heart and great vessels should be securely performed in the presence of a readily available cardiopulmonary bypass capability. © 2009 Forum Multimedia Publishing, LLC.

A strong component of predicted mortality in scoring systems is advanced age, however, outcomes data in nonagenarians (age >90 years) is lacking. We evaluated surgical outcomes after aortic valve replacement (AVR) in nonagenarians at our institution over an 11-year period. Demographics, procedural

Objectives Advanced age plays a major role in surgical risk algorithms; however, the outcomes data for the very elderly are lacking. We, therefore, evaluated the outcomes after surgical aortic valve replacement (SAVR) in nonagenarians (age, >90 years) at our institution during an 11-year period. Methods The demographics, procedural details, and in-hospital outcomes were retrospectively analyzed for 119 nonagenarians with symptomatic, severe aortic stenosis who had undergone SAVR or SAVR plus concomitant surgery from 2001 to 2012. The mean follow-up period was 915 ± 832 days. Results The average age was 91.7 ± 1.9 years (range, 90-98), and the mean Society of Thoracic Surgeons score was 8.9 ± 5.7. The mean aortic valve gradient was 45 ± 16 mm Hg, mean aortic valve area was 0.66 ± 0.2 cm 2 , and mean ejection fraction was 49.8% ± 11.8%; 47% underwent isolated SAVR. The average length of stay was longer than expected; however, the rates of prolonged ventilation (16.8%), new atrial fibrillation (43.7%), stroke (0.8%), and renal failure (5.9%) were acceptable. Three patients (2.5%) required reoperation for bleeding. Overall, the 30-day and 1-year mortality was 7.6% and 21.0%, respectively. The multivariate predictors of mortality at 1 year included previous myocardial infarction (hazard ratio, 2.79; 95% confidence interval, 1.21-6.45; P = .016), obstructive lung disease (hazard ratio, 3.90; 95% confidence interval, 1.66-9.15; P = .025), and diabetes (hazard ratio, 2.77; 95% confidence interval, 1.08-7.07; P = .033). The observed in-hospital mortality was lower than expected (observed/expected, 0.85). Conclusions Excellent procedural and long-term outcomes can be achieved in nonagenarians, and age alone should not be a contraindication to SAVR in selected populations. Our sample cohort has validated the feasibility of a primary operative strategy in elderly patients with aortic stenosis and acceptable risk profiles.

Concomitant surgeries for unrelated diseases can be performed to minimize the risks associated with surgery and general anesthesia. In treating a male patient with breast cancer and severe coronary artery disease, we used the beating heart technique for a coronary artery bypass graft to avoid the negative effects of on-pump bypass on the possible acceleration of tumor growth. In this report, we present a unique case of concomitant off-pump coronary artery bypass graft surgery and modified radical mastectomy in a 56-year-old man.

Congenitally corrected transposition of the great arteries, which is characterized by atrioventricular and ventriculoarterial discordance, is a rare congenital heart disease. Most of the cases are diagnosed in childhood, owing to associated cardiac anomalies, such as ventricular septal defect, pulmonary stenosis or pulmonary atresia, and Ebstein-like malformation of the tricuspid valve. We present a patient with congenitally corrected transposition of the great arteries who underwent surgical replacement of the tricuspid valve with a bioprosthesis and reconstruction of the left ventricular outflow tract with bovine conduit. © 2011 Forum Multimedia Publishing, LLC.

Background: Concomitant tricuspid valve repair (TVr) for functional tricuspid regurgitation (TR) at the time of left-sided valve surgery has become increasingly more common over the past decade. The impact of residual post-repair TR on late outcomes remains unclear.Methods: All patients undergoing TVr during concomitant left-sided valve surgery at our institution from 2005-2012 were retrospectively reviewed. Patients were stratified into 2 groups according to the degree of post-cardiopulmonary bypass TR observed on intraoperative transesophageal echocardiography; 0-1+ TR (No TR, n = 246) and ≥2+ TR (Residual TR, n = 26). Primary outcomes of interest were 30-day survival, 4-year survival, and follow-up TR grade. A propensity-matched subgroup analysis was performed in addition to the overall cohort analysis.Results: Mean age for all patients was 70.3 ± 13.0 years and 107 (39%) patients were male. There was no difference in 30-day survival between groups (92% No TR versus 96% Residual TR, P = .70). Kaplan-Meier analysis of overall 4-year survival showed a trend toward worsened survival in the Residual TR group (log rank P = .17) and propensity-matched subgroup analysis showed significantly worse 4-year survival for Residual TR (log rank P = .02). At mean echocardiographic follow up of 11.9 ± 22.5 months, TR grade was significantly worse in the Residual TR group compared to No TR (1.5 ± 0.8 Residual TR versus 0.9 ± 0.9 No TR, P = .005), although TR severity was significantly improved from immediately post-bypass. Conclusions: Patients left with residual TR following TVr during concomitant left-sided valve surgery have significantly decreased late survival compared to patients left with no post-repair TR.

Purpose A certain percentage of the left ventricular assist device (LVAD) patients inevitably require a device exchange. While it is clinically an important entity, only a handful of studies have been reported. Methods and Materials From Dec 2008 to Oct 2012, a total of 28 device exchanges (HeartMate II to HeartMate II) were performed. Since June 2011, we have employed the subcostal approach for device exchange if indicated. A full sternotomy was used in 13 cases (F group) and a subcostal approach was in 15 cases (S group). Preoperative and postoperative data were retrospectively reviewed. Results There was no difference in baseline patient characteristics between the two groups. Overall, mean duration between the primary implants and the device exchanges was 413±410 days. Surgical indications included device thrombus/hemolysis (N=18), device malfunction (N=8), and infection (N=2). Cardiopulmonary bypass time was significantly short in the S group (S: 40.2±24.1 min, F: 103.8±92.9 min, p 72hours) (F: N=5, S: N=1, p figure 1 ] Conclusions A subcostal approach is safe and would be preferred for HeartMate II device exchange if indicated.

Significant debate exists about when to intervene for residual tricuspid regurgitation (TR) after repair during concomitant mitral or aortic valve procedures. All patients undergoing tricuspid valve repair (TVr) during aortic and/or mitral valve (AV, MV) operations at our institution from 2005

The control of sternal bleeding during cardiac surgery can sometimes be a challenging and time-consuming problem for surgeons. Several alternatives for the control of sternal bleeding are on the market. Bone wax is a well-known alternative used by many cardiac surgeons for the control of bleeding. It is effective and cheap; however, it inhibits ossification of the sternum and can cause infections and sternal wound healing problems after cardiac surgery. Consequently, control of sternal bleeding without the use of bone wax requires meticulous preparation. Ankaferd Blood Stopper (ABS) (Ankaferd Sağlik Ürünleri, Istanbul, Turkey) is a unique folkloric medicinal plant extract that has been used in Turkish traditional medicine as a hemostatic agent. We present a practical alternative technique for the control of sternal bleeding during cardiac surgery with the use of ABS.

Sarcoidosis, a chronic granulomatous disease with unknown etiology and pathogenesis, affects the skin and many other organs and has a course characterized by remissions and relapses. We describe a patient with sarcoidosis, which we diagnosed retrospectively after we had difficulties in harvesting the left internal thoracic artery because of giant and disseminated mediastinal lymphadenopathies on the anterior thoracic wall during urgent coronary artery bypass surgery.

Purpose Orthotopic heart transplantation (OHT) due to cardiac amyloidosis (CAM) is controversial because of concerns about long-term survival and recurrence in the allograft. Since AL amyloid is a systemic disease we hypothesized that long term outcomes of OHT in CAM would differ between primary (AL) and transthyretin (ATTR) CAM. Methods and Materials We retrospectively reviewed 26 patients with CAM undergoing OHT surgery at our institution, from July 2001 to July 2012. Patients were grouped based on CAM type as having AL or TTR amyloidosis. The primary endpoint was all-cause mortality after OHT. Kaplan-Meier estimates were used to determine actuarial survival. Results When stratified into AL (n=15) and TTR (n=11) groups, patients were 51.2±7 and 55.8±8 years old (p=0.077), had preoperative serum creatinine of 1.33±0.45 and 1.75±0.89 (p=0.13), respectively, and included 69% males. Mean follow-up was 28.9±31.3 months (range 2-110). Corresponding in-hospital mortality was not noted. Of 15 AL patients undergoing successful OHT, stem cell transplantation was performed in 13 (3 prior to OHT) and 3 had recurrence of CAM whereas recurrence was not noted in TTR patients. Twelve patients (46%) died during follow-up; 9 AL patients and 3 with TTR. The mean survival time was 8± 29.9 months for the patients who died. Survival for CAM patients undergoing OHT was similar in both groups at 1 month. However, the AL group compared to TTR had significantly lower 5-year survival (44.4±13.2% vs. 71.4±17.1%; p = 0.029). [ figure 1 ] Conclusions Survival differs between AL and ATTR cardiac amyloidosis after OHT with a significantly better survival for TTR CAM patients.

Purpose Organ donation (OD) rates remain low worldwide, particularly in the eastern world. Attempts to increase OD rates have ranged from public awareness campaigns to financial incentives. We sought to examine the attitudes and potential ways to increase heart donation in this multi-ethnic region. Methods and Materials A web-based survey was administered to 3639 healthcare professionals (HP) and members of the public aged 18-64 throughout Turkey. 32 questions were asked addressing attitudes on OD,including if respondents would donate, strategies to increase OD and response to the use of incentives. Of those invited to respond, 34.4% completed the survey. Results Amongst respondents, 22% were HP,52% were women, 45% were between 25-35 years, and 69% were university graduates. 94% of participants supported organ donation and 93% would carry out the wishes of a family member with an organ donor card. However, only 37% were willing to donate, and 64% would consent for donation of a family member without a card. 77% believed family consultation should not be required if the donor had a signed donor card. Across all respondents 10% were against and 18% had no information on heart donation, and 11% believed OD is not permissible by their religion. 22% believed that people could recover from brain death. Presumed consent was acceptable to 63%, with 78% identifying it as a way to increase donation. Improved public education was identified by 53% as the single best way to increase donation. 60% believe religious leaders should be involved. 50% supported indirect compensation (donor hospital expenses forgiveness, funeral expenses, etc.); 52% supported direct incentives such as life insurance provisions. Conclusions Despite the high number of highly educated respondents, this survey still indicates a profound need for educational campaigns to increase the awareness of the public as well as HP,particularly with the support and involvement of religious and cultural leaders,in order to dramatically increase OD rates in Eurasia.