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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

Mitral valve repair has been one of the widely used applications of robotic surgery. Patients with rheumatic mitral disease usually present at an early age with thickening, retraction, or fusion of the leaflets and subvalvular apparatus. Robotic mitral repair can be feasible among this group of patients, rather than replacement. Herein, we describe a young woman who presented with rheumatic mitral valve insufficiency. A complex mitral repair with posterior leaflet extension with an autologous pericardial patch was successfully conducted using robot assistance.

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 objective is to demonstrate safety and early clinical results of surgical transapical closure of paravalvular leaks (PVLs) following mitral valve replacement in significant regurgitation. Between March 2014 and February 2015, 12 patients (mean age 52.1 ± 6.0 years, 66.6% male) with severe symptomatic mitral PVLs (n = 13) underwent surgical transapical closure procedure through left mini-thoracotomy. All patients were in NYHA functional class III-IV and median logistic EuroSCORE was 24.2 ± 6.4% (range, 13.5-34.6%). Indications were heart failure (n = 10) and symptomatic hemolysis (n = 2) due to severe mitral regurgitation (MR). Amplatzer Vascular Plug-III devices (n = 9) were used for smaller and regular defects; whereas Atrial Septal Defect closure devices (n = 4) were used for larger defects. Technical success was achieved in 10 (83.3%) patients. One (8.5%) patient with 2 + MR was treated medically. A patient with residual 4 + MR underwent re-operation. There was no procedure-related complication including mortality, device migration, embolization, or cardiac laceration. Mean procedure and fluoroscopy times were 166.4 ± 39.5 (range, 90-210) and 25.7 ± 17.3 (range, 16-64) minutes, respectively. The mean intensive care and hospital stays were 2.1 ± 1.3 and 10.3 ± 6.5 days, respectively. Clinical efficacy was achieved in 9 (75%) of 12 patients at early follow-up of 8.5 ± 2.1 months. NYHA status was class II in two patients, and no hemolytic anemia was diagnosed. Echocardiographic studies revealed a significant reduction of preoperative MR (3-4+) to less than 1+ MR after operations (P < 0.05). Surgical transapical approach to PVL closure is a safe and effective procedure following mitral valve replacement. Early results show that this procedure can be an alternative to re-operation for high-risk patients. Further studies are needed to prove its effectiveness in the long term.

Background The purpose of this study is to assess the electrocardiographic and electrophysiological parameters of conduction abnormalities in patients undergoing transcatheter aortic valve implantation (TAVI) due to severe aortic valve stenosis. Methods The study included 55 patients who underwent TAVI using either the Boston Scientific Lotus (n:25) (Boston Scientific, Natick, MA, USA) or Edwards Sapien XT (n:30) (Edwards Lifesciences, Irvine, CA, USA) prostheses. An electrophysiological study (EPS) was performed in the catheterization room immediately before the initial balloon valvuloplasty and immediately after prosthesis implantation. Results QRS duration and His-bundle to His-ventricle (HV) intervals, which were similar between the two groups before the procedure, were found to be significantly higher in the Lotus valve group postprocedure. Permanent pacemakers (PPMs) were required more frequently in the Lotus group than in the Sapien XT group at discharge (24.0% vs 6.7%, P = 0.07). With the exception of a higher prevalence of paravalvular leakage (P < 0.001) in patients undergoing Sapien XT implantation, other clinical outcomes were similar between the two groups. Multiple regression analysis revealed that baseline atrioventricular (AV) conduction disorders and HV intervals after the procedure were independently associated with PPM implantation after TAVI. Conclusion In this first study comparing the findings of EPS and electrocardiography, the impact of the Lotus valve on AV conduction systems was greater than that of the Sapien XT. However, the need for PPM was higher in the Lotus valve than in the Sapien XT. PPM requirement is related to valve design; it may decrease with reduced frame height and metal burden in novel valve systems.

The aim of the study is to evaluate extracorporeal life support system (ECLS) employed in neonates in pediatric cardiac intensive care unit.Twenty-five neonates that required ECLS in between November 2010 and November 2015 were evaluated.The median age was 12 days (range 3-28 days) and the median body weight was 3 kg (range 2.5-5 kg). Venoarterial ECLS was performed in all of the cases. Ascendan aorta-right atrial cannulation in 22 patients and neck cannulation in three patients were performed. The reason for ECLS was E-CPR in two patients, inability to wean from cardiopulmonary bypass (CPB) in seven patients, respiratory insufficiency and hypoxia in nine patients, low cardiac output (LCOS) in seven patients. Median duration of ECLS was four days (range 1-15). Hemorrhagic complications developed in 15, renal complications in 13, pulmonary complications in 12, infectious complications in 11, neurologic complications in three and mechanical complications in two of the patients. Weaning was successful in 15 of the patients. Eleven patients were successfully discharged.ECLS is an important treatment option that is performed successfully in many centers around the world to maintain life support in patients unresponsive to medical treatment. The utilization of this modality especially in newborns with congenital heart disease should be taken into consideration.

Situs inversus totalis (SIT) with dextrocardia is an uncommon congenital positional anomaly, which is characterized by a symmetrical 'mirror-image' orientation of all organs in relation to the midline. Although sternotomy and thoracotomy is traditionally used in patients with SIT with dextrocardia, a totally endoscopic robotic surgery is an alternative surgical approach to intracardiac anomalies. Placement of robotic ports, transthoracic aortic clamp, cardioplegia delivery, and peripheral vascular cannulation is made from the left side of the chest, as a mirror orientation of the right-sided robotic cardiac procedures. Here, we present a patient who underwent concomitant robotic atrial septal defect closure and tricuspid annuloplasty with posterior plication using the da Vinci surgical system.

ObjectiveOxidative stress refers to an imbalance between reactive oxidative species and antioxidants. In this case-controlled, prospective, observational study, we investigated the total oxidant status, total antioxidant status, oxidative stress index, and albumin and C-reactive protein levels of children with cyanotic and acyanotic congenital heart diseases who had undergone on-pump cardiac surgery.MethodThe study groups consisted of 60 patients with congenital heart disease, who were operated under cardiopulmonary bypass, and a control group of 30 healthy individuals. The patients were classified into two groups. Among them, one was a patient group that consisted of 30 patients with acyanotic congenital heart disease and the other group consisted of 30 patients with cyanotic congenital heart disease. In the patient groups, blood samples were collected before surgery and at one and 24 hours following surgery. In control groups, blood samples were collected once during hospital admission.ResultsNo statistically significant differences were found between the groups in terms of baseline total oxidant status, total antioxidant status, and oxidative stress index values. Regarding the postoperative first-hour and 24-hour total oxidant status and total antioxidant status levels as well as oxidative stress index values, there were no significant differences between the groups, except for an increase in total antioxidant status levels (p=0.002) 24 hours after surgery in cyanotic patients.ConclusionThere was no difference between oxidative stress status of cyanotic and acyanotic congenital heart disease patients and healthy individuals. Oxidative stress status of cyanotic and acyanotic patients does not change after cardiac surgery under cardiopulmonary bypass.

Partial anomalous venous return from the right lung to the right atrium is a rare congenital heart anomaly in adults. We report a 20-year-old female, who presented with right partial anomalous pulmonary venous return and an associated inferior atrial septal defect. A complex repair was successfully done through a right atriotomy approach using a robotic surgical system. doi: 10.1111/jocs.12753 (J Card Surg 2016;31:394-397).

Background This study sought to compare various outcomes among a new specifically designed transcatheter paravalvular leak closure (TPVLC) device and the devices that are being utilized off-label. Methods Between April 2012 and January 2015, in a prospective two-center study, 52 patients who needed surgical reintervention due to a hemodynamically significant prosthetic paravalvular leak were studied. This study population was divided into two groups. Group I was composed of 32 patients who underwent paravalvular leak (PVL) closure with the currently available devices that are being utilized off-label, while group II consisted of 20 patients who were treated with the new specifically designed Occlutech PVL device. Results Demographic and clinical variables indicated a higher rate of atrial fibrillation (P = 0.027) and chronic obstructive airway disease (P = 0.009) in group II. The apical approach was the most commonly used intervention route used for group II (P = 0.019). The procedural success rate was 100% (29 of 29 leaks) in group II while the rate was 92% (39 of 42 leaks) in group I. However, more secondary events were observed in group I, but they did not reach statistical significance (8 vs. 1, P = 0.064). Conclusions With its high procedural success rate and encouraging outcome results, the Occlutech device seems to satisfy the expectations of a specifically designed PVL closure device. © 2016 Wiley Periodicals, Inc.

Familial hypercholesterolemia is an uncommon disease that may be associated with atherosclerosis affecting coronary arteries and the ascending aorta. Coarctation of the aorta is rarely involved in this disease. The ideal surgical approach for management of coexisting coronary artery disease and coarctation of the aorta in a child with familial hypercholesterolemia is unclear. We report the case of a 14-year-old girl with familial hypercholesterolemia who underwent double coronary artery bypass grafting due to proximal lesions of both the left anterior descending artery and the right coronary artery.

BACKGROUND Systemic-pulmonary shunts are widely used in initial palliation in cyanotic congenital heart disease. The incidence and the relationship between acute shunt obstruction and thrombophilia are not precisely defined. The aim of this study was to determine the frequency of shunt obstruction in the early postoperative period, and to define the frequency and presence of thrombophilia factors in patients treated for acute shunt thrombosis. METHODS Between October 2010 and October 2012, 77 patients who had systemic-pulmonary shunt operation were included in this prospective study. Patients who developed shunt obstruction were examined in terms of inherited and acquired thrombophilia factors. RESULTS Median patient age was 61 days and median weight was 4.3 kg. Thirty-three patients were neonates. Diameter of the Gore-Tex grafts used for the shunt ranged from 3 mm to 5 mm. Acute shunt occlusion rate was 10% (8/77), and all of these occurred in the first 24 h. Thrombophilia was found in three of eight patients who underwent intervention (surgical and/or transcatheter) due to shunt thrombosis (presence of anti-phospholipid antibodies, n = 1; protein C deficiency, n = 1; and factor V Leiden mutation, n = 1) and only one patient died. CONCLUSIONS Acute shunt obstruction developed in 10% of patients who underwent systemic-pulmonary shunt, and emergency surgery or transcatheter intervention can be life saving in this context. Acute shunt obstruction can occur due to mechanical and hemodynamic problems, but clinicians should also consider and evaluate thrombophilia factors.

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.

Background We evaluated the preoperative, operative and postoperative risk factors affecting early mortality in patients who underwent total correction of tetralogy of Fallot (TOF). Methods One hundred and twenty-two TOF patients who underwent reparative surgery between January 2010 and November 2013 were enrolled in the study. Results Mean patient age and weight was 2.3 ± 2.5 years and 11.3 ± 6.4 kg, respectively. Cardiac catheterization was performed in 101 patients (83%),and coronary anomalies were found in 11 patients. Mean McGoon index, pulmonary annulus z-score, main pulmonary artery z-score, left pulmonary artery z-score and right pulmonary artery z-score were 2.0 ± 0.4, –1.85 ± 1.54, –2.84 ± 2.06, 1.17 ± 1.73, and 0.74 ± 1.57, respectively. Total reparative surgery with a transannular patch was performed in 97 patients (79.6%); the rest underwent valve-sparing surgery. Median duration of postoperative mechanical ventilation, intensive care and hospital stay were 19 h, 3 days and 9 days, respectively. Extracorporeal membrane oxygenation (ECMO) was required in 10 patients in the postoperative early period. Arrhythmias occurring in the early postoperative period were junctional ectopic tachycardia (n = 13), complete atrioventricular block(n = 10; permanent epicardial pacemaker implanted in four) and ventricular tachycardia (n = 4). Nine patients died in the early postoperative period (7.3%). Parameters found to be associated with increased mortality were low preoperative oxygen saturation; high right ventricular/aortic pressure ratio immediately after surgery; presence of coronary anomaly; requirement of postoperative ECMO; and pacemaker (P = 0.02, P = 0.04, P = 0.01, P = 0.0001, P = 0.03, respectively). Conclusions Poor preoperative oxygenation, presence of coronary anomaly, complete AV block in the early postoperative period, high RV pressure and requirement of ECMO appear to be the most significant factors that affect early mortality in the surgical treatment of TOF. Appropriate preoperative assessment, correct surgical strategies and attentive intensive care monitoring are required in order to reduce mortality.

Endovascular aneurysm repair is being used more often and replacing open surgical repair as the treatment option for aortic aneurysm. Early results are better than those of open surgical repair, but the need for a second intervention is greater. Excision of a previously placed stent-graft by different surgical methods is very difficult and has high mortality and morbidity rates. We describe 3 patients who had previous endovascular aneurysm repair and were treated by an open surgical method with near total excision, leaving part of the stent-graft in the native aortic tissue.

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.

Exposure of the mitral valve can be challenging using conventional sternotomy and thoracotomy incisions in patients with pectus deformity. We report the use of a robotic approach to replace a rheumatic mitral valve in a patient with pectus excavatum. doi: 10.1111/jocs.12740 (J Card Surg 2016;31:306-308).

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.

BACKGROUND The use of blood products is not uncommon during cardiac surgery in elderly patients. We conducted this study to investigate the risk factors and adverse outcomes of increased red blood cell (RBC) transfusion in the patients aged ≥ 65 years undergoing cardiac surgery. METHODS During 1 year period, 288 patients (197 male/91 female) aged ≥ 65 years who underwent coronary and/or valvular surgery were retrospectively reviewed. Patients were stratified into groups on the basis of the number of transfusions received (< 4 and ≥ 4 U) which was classified as increased transfusion. Univariate analysis and multivariate logistic regression were used to identify risk factors for increased transfusion. RESULTS The mean unit of RBC transfusion was 4.5 ± 3.1 and 55.9% (n = 161) of patients received ≥ 4 U RBC. The overall postoperative complication rate was 36% and significantly higher in those with ≥ 4 U) RBC transfusion (p

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.

Objective: To investigate the efficacy of dornase alpha, a mucolytic agent, in children who developed pulmonary atelectasis after congenital heart surgery. Design: Retrospective case–control study. Setting: Paediatric cardiac intensive care unit at a tertiary care hospital. Patients: Between July, 2011 and July, 2012, 41 patients who underwent congenital cardiac operations and developed post-operative pulmonary atelectasis that was resistant to conventional treatment and chest physiotherapy. Interventions: In all, 26 patients received dornase alpha treatment. As a control group, 15 patients were treated with conventional medications and chest physiotherapy. Main results: The median age of patients was 25.5 (3–480) days in the study group and 50.0 (3–480) days in the control group. A total of 15 (57.6%) patients in the study group and 8 (53.3%) patients in the control group were male. The median weight was 4.2 (2.9–14.2) kg and 4.0 (3.5–13.6) kg in the study and control group, respectively. In the study group, pulmonary atelectasis was diagnosed at a median period of 5 (2–18) days after operations, whereas in the control group atelectasis was diagnosed at a median period of post-operative 6 (3–19) days. In the study group, the median atelectasis score decreased from 3.4 (1–6) to 0.8 (0–3) (p = 0.001). The median pO2 level increased from 69 (17–142) mmHg to 89 (30–168) mmHg (p = 0.04). In addition, heart rate and respiratory rate per minute were significantly decreased (p < 0.05). There were no significant changes in these parameters in the control group. Conclusions: The use of dornase alpha can be effective for the management of pulmonary atelectasis that develops following congenital heart surgery.

Background Oxytocin (OXY) is a well-known nonapeptide that functions in reproduction. It is also known as an antioxidant in several organs. However, little is about its role in the protection of tissue against ischemia/reperfusion injury in skeletal muscle. The aim of this study was to evaluate the protective and therapeutic antioxidant effect of oxytocin in skeletal muscle during ischemia/reperfusion (I/R) injury. Methods Rats were divided into 4 groups. Hindlimb ischemia was achieved by clamping the common femoral artery in 3 of the groups, but not a control group. OXY was injected before ischemia in the preoperative (preop) I/R + OXY group and after the onset of ischemia in the postoperative (postop) I/R + OXY group. Saline solution was injected in the I/R group. Limbs were rendered ischemic for 90 min. At the end of 90-min reperfusion period, skeletal muscle tissue samples were taken from the ischemic muscle for evaluation at light and transmission electron microscopic levels. Biochemical analysis was done for malonedialdehyde and glutathione levels. Caspase immunohistochemistry was applied for apoptosis. Results The light- and electron-microscopic scores of the OXY-treated groups were significantly lower than in the I/R group. The degree of tissue damage was ameliorated in the OXY-treated groups. The number of apoptotic cells was decreased in the OXY-treated groups compared with the I/R group. In OXY-treated groups, the malonedialdehyde level was lower than in the I/R group. Glutathione levels were found to be increased in the OXY-treated groups compared with the I/R group. Conclusions Oxytocin has a protective effect against I/R injury in skeletal muscle and may reduce the incidence of compartment syndrome.

Extracorporeal life support (ECLS) provides mechanical support following cardiac surgery when respiratory and cardiac failure occurs. We retrospectively reviewed medical records of patients who needed ECLS at a new congenital heart center in Turkey. Between December 2009 and February 2012, 616 congenital heart operations were performed. A total of 13 patients (seven female) underwent ECLS. The ages of the patients ranged between 16 days and 33 years. There were two neonatal, seven infant, three pediatric, and one adult congenital cases. Medos DPII ECLS system was used in all patients. Mean duration of ECLS was 6.2 ± 5.8 days (ranged from 29 h to 24 days). While central vascular access with aorta and right atrial cannulation was used in 11 patients, neck vessels were used in the other patients. Four patients (30.7%) weaned successfully from ECLS (two infant, two pediatric cases). Three of them had ECLS intraoperatively. In all patients, two (15.4%) were discharged from the hospital. One of them had mild neurologic deficit. Bleeding from the surgical and cannulation sites was the most common complication. Thrombus was detected in pump head and changed uneventfully in three patients. Arterial pH and lactate levels at the beginning of ECLS were significantly lower in patients who were successfully weaned from ECLS than nonsurvivors (P = 0.04 and P = 0.02, respectively). ECLS can be a lifesaving modality in the perioperative period. It may be more beneficial if ECLS is used before the development of severe acidosis and high lactate levels.

Pulmonary atresia with intact ventricular septum (PAIVS) is characterized by a broad spectrum of heterogeneous morphologies. Perforation of the atretic valve, balloon dilatation, and stenting of the patent ductus arteriosus are the percutaneous techniques that are used with increasing frequency in our clinic as well. They have some advantages over surgery, including short hospital stay and short intensive care unit stay. The main goal of the primary interventional approach is to avoid surgery. However, a group of patients with PAIVS still need surgery due to poor right ventricular growth. Therefore, the final achievement of the initial percutaneous treatment strategies is still debatable. In this article, we present the early- and mid-term results of the percutaneous approach utilized at our clinic in order to investigate the final effects of interventional therapy according to initial morphology. Between May 2010 and May 2012, 15 neonates diagnosed with PAIVS underwent transcatheter intervention. Detailed echocardiographic examination focused on right ventricle size, and tricuspid valve morphology and coronary sinusoids were performed in all the patients before the intervention. Nine of the patients were boys and six were girls. The mean age was 11.40 ± 12.87 days and mean weight was 3.34 ± 0.46 kg. Only one procedure-related mortality occurred. The mean follow-up period was 10.05 ± 3.42 months (1-26 months). The mean duration of intensive care was 7.19 ± 5.14 days. The mean follow-up time was 10.05 ± 3.42 months. After this period, survival rate was 66% (10/15). Two of the patients achieved biventricular physiology after pulmonary valve perforation. Two patients still have univentricular physiology. Six patients have been followed as a one and half ventricle repair candidate. Five out of 15 patients had stent patency during 6 months of follow-up, while restenosis developed in one patient (1/5, 20%), who had undergone the Glenn operation at 5 months of age. Transcatheter management for PAIVS is a feasible, safe, and effective primary palliative treatment in newborns. Shunt surgery may be considered in cases where cyanosis occurs despite transcatheter intervention. Right ventricular size determines the type of intervention. The early outcomes can be comparable with surgical palliation. However, a group of PAIVS, particularly with severe right ventricular hypoplasia, needs surgery even after a successful primary percutaneous intervention.

This study summarizes the clinical outcome data of a start-up congenital heart surgery program in Turkey. Between December 2009 and February 2012, 616 operations have been performed in 132 newborns (22%), 260 infants (42%), and 224 children/adolescents (36%). Risk adjustment analysis was performed using the risk adjustment in congenital heart surgery (RACHS-1) risk assessment model. There were 66 mortalities (10.7%). According to the RACHS-1 categories, there were 51 cases in level I (8.2%) with no mortality (0%), 250 in level II (40.6%) with 11 (4.4%) mortalities, 199 in level III (32.3%) with 33 (16.5%) mortalities, 53 in level IV (8.6%) with 10 (18.8%) mortalities, 14 in level V and VI (2.2%) with 11 (78.5%) mortalities, and 49 cases (7.9%) out of the RACHS-1 categories with one (2.0%) mortality. Mortality was higher in neonates compared to infants, and in infants compared to children/adolescents. Mortality was higher in palliative procedures compared to corrective procedures. The data demonstrate that a start-up program with a relatively loaded surgical volume may achieve acceptable clinical results with a good teamwork. Collaboration of anesthesiologists, perfusionists, pediatric cardiologists, intensivists, and cardiovascular surgeons is necessary to provide a better outcome in congenital heart surgery.

The Eighth International Conference on Pediatric Mechanical Circulatory Support Systems and Pediatric Cardiopulmonary Perfusion was held at the Galatasaray University, Istanbul, Turkey, June 13–16, 2012 (Fig. 1).Atif Akcevin, MD, was the local chair of the conference. The scientific co-chairs of the eighth event were Atif Akcevin, Tijen Alkan-Bozkaya, Ihsan Bakir, Hakan Ceyran, Yves Durandy, Huriyet Ersayin-Kantas, Colleen E. Gruenwald, David Palanzo, Linda Pauliks, Kerem Pekkan, Chitra Ravishankar, Eugen Sandica, Kyung Sun, Riza Turkoz, Akif Undar, Bonnie Weaver, and John L. Myers. As we stated in the past seven editorials, the overall objective of the meeting was and still is to bring together internationally known clinicians, bioengineers, and basic scientists involved in research on pediatric mechanical circulatory support systems and pediatric cardiopulmonary bypass procedures. Primarily, we focus to explicitly describe the problems with current pediatric mechanical circulatory support systems, methods, and techniques during acute and chronic support and to suggest solutions and future directions for research (1–3). Over 200 participants from 20 countries participated at the eighth annual event. One hundred one formal presentations including a keynote lecture, 40 invited lectures, 29 oral, and 32 poster presentations began on Thursday morning June 14, 2012 and continued through Saturday evening June 16, 2012. To date, over 800 presentations (320 invited lectures, 220 slide, and 260 poster presentations) and 400 peer-reviewed articles were published based on this unique event (http://pennstatehershey.org/web/ pedscpb/home). It was a great honor to have William S. Pierce, MD, from Penn State Hershey College of Medicine, as the keynote lecturer. His lecture entitled “A 40-Year Odyssey in Mechanical Circulatory Support” was a great historic lecture and it was a privilege to listen to his talk (Figs. 2 and 3a,b). In addition, platform presentations took place in 2-h blocks during the morning and afternoon sessions on Thursday, Friday, and Saturday. Plenary sessions were held throughout the conference focusing on key topics including “Managing the Single Ventricle Patient from Fetus to Definite Treatment” (led by co-chairs David Anderson, MD, and John L. Myers, MD), “Pediatric MCS—Devices & Outcomes” (led by co-chairs William S. Pierce, MD, and Kyung Sun, MD, PhD, MBA), “Bioengineering Approaches in Pediatric Cardiovascular Medicine” (led by Akif Undar, PhD, and Jeffrey D. Zahn, PhD), “Extracorporeal Life Support” (led by Chitra Ravishankar, MD, and Bonnie Weaver, RN, CCRN), “Multi-Disciplinary Team Approach to Solve the Complex Problems in Neonatal and Pediatric Cardiac Surgery” (led by Ihsan Bakir, MD [Turkey], and Tayyar Sarioglu, MD), “Cardiopulmonary Perfusion” (led by Colleen E. Gruenwald, PhD, and David Palanzo, CCP), “Myocardial Protection during CPB” doi:10.1111/j.1525-1594.2012.01562.x FIG. 1. Halil Tűrkoglu, William S. Pierce, PeggyJayne Pierce, Akif Undar, Ihsan Bakir, and John L. Myers. bs_bs_banner

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.

The objective is to demonstrate safety and early clinical results of surgical transapical closure of paravalvular leaks (PVLs) following mitral valve replacement in significant regurgitation. Between March 2014 and February 2015, 12 patients (mean age 52.1 ± 6.0 years, 66.6% male) with severe symptomatic mitral PVLs (n = 13) underwent surgical transapical closure procedure through left mini-thoracotomy. All patients were in NYHA functional class III-IV and median logistic EuroSCORE was 24.2 ± 6.4% (range, 13.5-34.6%). Indications were heart failure (n = 10) and symptomatic hemolysis (n = 2) due to severe mitral regurgitation (MR). Amplatzer Vascular Plug-III devices (n = 9) were used for smaller and regular defects; whereas Atrial Septal Defect closure devices (n = 4) were used for larger defects. Technical success was achieved in 10 (83.3%) patients. One (8.5%) patient with 2 + MR was treated medically. A patient with residual 4 + MR underwent re-operation. There was no procedure-related complication including mortality, device migration, embolization, or cardiac laceration. Mean procedure and fluoroscopy times were 166.4 ± 39.5 (range, 90-210) and 25.7 ± 17.3 (range, 16-64) minutes, respectively. The mean intensive care and hospital stays were 2.1 ± 1.3 and 10.3 ± 6.5 days, respectively. Clinical efficacy was achieved in 9 (75%) of 12 patients at early follow-up of 8.5 ± 2.1 months. NYHA status was class II in two patients, and no hemolytic anemia was diagnosed. Echocardiographic studies revealed a significant reduction of preoperative MR (3-4+) to less than 1+ MR after operations (P 0.05). Surgical transapical approach to PVL closure is a safe and effective procedure following mitral valve replacement. Early results show that this procedure can be an alternative to re-operation for high-risk patients. Further studies are needed to prove its effectiveness in the long term.

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