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OBJECTIVE: We aimed to identify characteristics differentiating patients undergoing mitral valve replacement versus valve repair for mitral regurgitation (MR) and to investigate retrospectively mid-term clinical and functional outcomes. METHODS: From January, 2004 to January, 2009 146 patients underwent mitral valve surgery (62 male / 84 female; age: 55.9+/-13.6 [18-80] years) by one surgical team. Mitral valve replacement was performed in 101 patients (69.2%) and valve repair was performed in 45 patients (30.8%). Mean follow-up time was 586+/-413 days. Life tables were constructed for the analysis of 5-year complication free survival and comparisons were performed between the groups using Log-rank test within 95%CI. RESULTS: The choice of surgical technique depended on the etiology of MR. Degenerative (p=0.001) and ischemic (p=0.014) MR were more common in patients undergoing repair whereas patients with complex rheumatic mitral valve disease (p=0.001) with subvalvular involvement commonly underwent replacement. Overall 30-day mortality was 3.2% (replacement, 3.96%vs repair, 2.22%, p=0.59). Although there was no significant difference between the groups regarding baseline left ventricular ejection fraction (EF) (ischemic p=0.61; non-ischemic p=0.34), improvement was more pronounced in the repair group for both etiologies (ischemic MR, p=0.001; non- ischemic MR p=0.002). Survival at 5-years was 91.7+/-4.7% after repair and 83.5+/-9.2% after replacement, respectively (p=0.83). Freedom from grade 2 or more mitral regurgitation, reoperation, endocarditis, and thromboembolism were 95+/-5% vs 97+/-3% (p=0.71); 95+/-4% vs 98+/-2% (p=0.98); 94+/-4% vs 100% (p=0.16); and 85+/-8% vs 100% (p=0.095) in replacement and repair groups, respectively. CONCLUSION: This study demonstrates that mitral valve repair is associated with an acceptable operative mortality, satisfactory mid-term survival and better preservation of left ventricular function. Significant differences in favor of repair are expected in long-term follow-up particularly regarding freedom from thromboembolism and endocarditis. [ABSTRACT FROM AUTHOR]

In the era of proton-antiproton collisions, stem cell field has emerged as the newly recognized protons of regenerative medicine. Great interest and enthusiasm were depending on their behavioral difference such as self-renewal, clonogenicity and differentiation into functional progeny that may become vehicles for regenerative medicine. Although progress has evolved dramatically strategies using stem-cell-driven cardiac regeneration involve extremely complex and dynamic molecular mechanisms. Cell death in transplanted heart continues to be a significant issue. Every step from stem cell homing, and migration to retention, engraftment, survival and differentiation in cardiac cytotherapy deserves intense research for optimum results. Furthermore, regeneration of contractile tissue remains controversial for human studies and careful interpretation is warranted for modest benefit in clinical trials. Currently, the only realistic approach to replace the damaged cardiomyocytes is cardiac transplantation for patients with end-stage heart failure. Ultimately, the giant footsteps in cell-based cardiac repair can only be achieved by an enthusiastic but also skeptical teams adhering to good manufacturing practices. Better understanding of cell-fate decisions and functional properties in cardiac cytotherapy may change the erosion of initial enthusiasm and may open new prospects for cardiovascular medicine. [ABSTRACT FROM AUTHOR]

The present review addresses the issues related to innovative contributions in biotechnology and their potential role in stem cell research at present and in the future. We can expect that future developments and applications in biotechnological sciences and industry will effect the direction of emerging cellular therapies. The use of these advances may offer a unique opportunity to investigate the mechanisms related to the journey from embryonic cells or bone-marrow derived stem/progenitor cells to cardiomyocytes or endothelial cells and the molecular regulators of cell differentiation. [ABSTRACT FROM AUTHOR]

Aneurysms of the left main coronary artery are rare clinical entities with an incidence of 0.1%. We herein report a case of left main trifurcation aneurysm in a 57-year-old woman whose coronary angiography demonstrated a giant saccular aneurysm of trifurcation of the left main coronary artery, measuring 32 × 21 mm with tight post-aneurysmal stenosis in the intermediate artery. The patient underwent coronary artery bypass grafting following the resection of CAA and reconstruction with saphenous vein roof-plasty, which ensured the preservation of the native coronary vasculature. At the 6-month follow-up, she remained asymptomatic and preserved preoperative left ventricular function., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The objective was to investigate the outcomes of concomitant venoarterial extracorporeal membrane oxygenation (ECMO) and left ventricular unloading with Impella (ECPELLA) compared with ECMO alone to treat patients affected by cardiogenic shock. Data from patients needing mechanical circulatory support from 4 international centers were analyzed. Of 438 patients included, ECMO alone and ECPELLA were adopted in 319 (72.8%) and 119 (27.2%) patients, respectively. Propensity score matching analysis identified 95 pairs. In the matched cohort, 30-day mortality rates in the ECMO and ECPELLA were 49.5% and 43.2% ( P = 0.467). The incidences of complications did not differ significantly between groups ( P = 0.877, P = 0.629, P = 1.000, respectively). After a median follow-up of 0.18 years (interquartile range 0.02-2.55), the use of ECPELLA was associated with similar mortality compared with ECMO alone (hazard ratio 0.81, 95% confidence interval 0.54-1.20, P = 0.285), with 1-year overall survival rates of 51.3% and 46.6%, for ECPELLA and ECMO alone, respectively. ECMO alone and ECPELLA are both effective strategies in patients needing mechanical circulatory support for cardiogenic shock, showing similar rates of early and mid-term survival., Competing Interests: Disclosure: The authors have no conflicts of interest to disclose., (Copyright © ASAIO 2024.)

Introduction: Extracranial internal carotid stenosis (EICS) is a well-established cause of stroke. Carotid near-occlusion (CNO), either distally collapsed or not, is a rare sub-type of EICS with conflicting data regarding the necessity for treatment. The aim of this study is to evaluate the results of carotid artery stenting (CAS) for patients with symptomatic CNOs., Material and Methods: Institutional review board (I06-420-23) approval was obtained for this retrospective study. Consecutive data from January 2019 to January 2023 was obtained. Sixty-five patients underwent 66 procedures for symptomatic CNOs. Diagnosis of CNOs were made with DSA images. Treatment decisions were made by a multidisciplinary team. Patient data including age, gender, clinical presentation, affected side, complications (initial/ follow-up), and pre and post mRS scores were recorded and analyzed., Results: There were 22 female and 43 male patients with symptomatic CNOs (mean age: 71.52 ± 9.32 years). The mean time from symptom-to-treatment was 3.91 weeks ± 3.74 weeks (ranging from 0 to 20 weeks). There were eight events recorded in the 30 days period after CAS; five (7.7%) were cerebral hyperperfusion syndrome (one causing haemorrhage) and three (4.5%) ischemic complications. Permanent neurologic deficit rate was 6% and 61 patients (94%) mRS scores were unchanged during last follow-up. Mean follow-up period was 22.94 ± 16.67 months (ranging from 0.5 to 60 months)., Conclusion: Our study demonstrated that in the complex population of patients with symptomatic CNOs, CAS is a feasible option with acceptable rate of permanent neurologic deficits. Further studies are needed to assess its safety and long-term efficacy., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: This study assessed vascular complications in patients who received extracorporeal membrane support following cardiac surgery. Methods: We included 84 post-cardiotomy patients who underwent extracorporeal membrane oxygenation (ECMO) from July 2018 to May 2022. Only patients connected to VA-ECMO (Veno-Arterial) via peripheral cannulation were included in this study. Vascular complications were compared between those who had ECMO placed using the percutaneous technique ( n = 52) and those who had it placed via femoral incision ( n = 32). Results: The incidence of vascular thromboembolism was significantly higher in the percutaneous technique group compared with the open technique group ( p < 0.05). Hematomas were also more frequent in the percutaneous technique group ( p = 0.04). Conversely, bleeding and leakage were significantly more frequent in the open technique group ( p = 0.04). There were no significant differences between the two groups in terms of wound infections or revisions in the inguinal area following ECMO removal. The mortality rate associated with vascular ischemia was 81.2%, while the overall in-hospital mortality rate was 60.7%. Conclusions: The open technique for ECMO placement may reduce the risk of thromboembolic events and hematomas compared to the percutaneous technique. However, it may be associated with a higher incidence of bleeding and leakage. Both techniques show similar outcomes in terms of overall mortality and wound infections.

Background: The initial extracorporeal membrane oxygenation (ECMO) configuration is inefficient for patient oxygenation and flow, but by adding a Y-connector, a third or fourth cannula can be used to support the system, which is called hybrid ECMO., Methods: This was a single-center retrospective study consisting of patients receiving hybrid and standard ECMO in our PICU between January 2014 and January 2022., Results: The median age of the 12 patients who received hybrid ECMO and were followed up with hybrid ECMO was 140 (range, 82-213) months. The total median ECMO duration of the patients who received hybrid ECMO was 23 (8-72) days, and the median follow-up time on hybrid ECMO was 18 (range, 3-46) days. The mean duration of follow-up in the PICU was 34 (range, 14-184) days. PICU length of stay was found to be statistically significant and was found to be longer in the hybrid ECMO group ( p = 0.01). Eight (67%) patients died during follow-up with ECMO. Twenty-eight-day mortality was found to be statistically significant and was found to be higher in the standard ECMO group ( p = 0.03). The hybrid ECMO mortality rate was 66% (decannulation from ECMO). The hybrid ECMO hospital mortality rate was 75%. The standard ECMO mortality rate was 52% (decannulation from ECMO). The standard ECMO hospital mortality rate was 65%., Conclusions: Even though hybrid ECMO use is rare, with increasing experience and new methods, more successful experience will be gained. Switching to hybrid ECMO from standard ECMO at the right time with the right technique can increase treatment success and survival., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: In this study, we aimed to evaluate the duration of extracorporeal membrane oxygenation (ECMO) and its effect on outcomes. Also, we sought to identify hospital mortality predictors and determine when ECMO support began to be ineffective., Methods: This was a single-center, retrospective cohort study conducted between January 2014 and January 2022. The prolonged ECMO (pECMO) cut-off point was accepted as 14 days., Results: Thirty-one (29.2%) of 106 patients followed up with ECMO had pECMO. The mean follow-up period of the patients who underwent pECMO was 22 (range, 15-72) days, and the mean age was 75 ± 72 months. According to the results of our heterogeneous study population, life expectancy decreased dramatically towards the 21st day. Hospital mortality predictors were determined in the logistic regression analysis in all ECMO groups in our study as high Pediatric Logistic Organ Dysfunction (PELOD) two score, continuous renal replacement therapy (CRRT) use, and sepsis. The pECMO mortality was 61.2% and the overall mortality was 53.0%, with the highest mortality rate in the bridge-to-transplant group (90.9%) because of lack of organ donation in our country., Conclusions: In our study, the PELOD two score, presence of sepsis, and use of CRRT were found to be in the predictors of in-hospital ECMO mortality model. Considering the complications, in the COX regression model analysis, the factors affecting the probability of dying in patients followed under ECMO were found to be bleeding, thrombosis, and thrombocytopenia., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Extracorporeal membrane oxygenation (ECMO) is a life-saving treatment option providing cardiopulmonary support when standard therapies prove insufficient for reversible diseases. The mean objective of this study was to evaluate our center's experience with ECMO following pediatric cardiac surgery. This retrospective study was conducted in our pediatric intensive care unit (PICU) between November 2014 and March 2021 and included patients who received ECMO following cardiac surgery. Over the 7-year period, 324 patients underwent cardiac surgery, of which 24 (7.4%) required ECMO support. Among them, 13 (54.2%) were female, with a median age of 16.0 (2.0- 208) months and a median weight of 7.0 (3.5-70) kg. The mean vasoactive inotrope score (VIS) was 53.9 ± 44.5. Atrioventricular septal defect repair was the most common surgical procedure (n = 8/24, 41.6%). The primary indication for ECMO was low cardiac output syndrome (LCOS) in 14 (58.3%) patients. The median duration of ECMO support was 6.0 (1.0-46.0) days. Nonsurvivors had significantly higher Pediatric Risk Score of Mortality (PRISM) III scores (P = .014) and VIS scores during the pre-ECMO period (P = .004). Early or late neurological complications developed in 12 (50%) patients, with significant differences in lactate levels and pH levels preECMO between those with and without neurological complications (P = .01, P = .02, respectively). We successfully decannulated 16 (66.6%) patients, with a final survival rate of 12 (50%). ECMO plays a crucial role in providing pre- and post-cardiac surgery support for children. LCOS remains the main indication, and high PRISM III and VIS scores are valuable predictors of outcomes.

Introduction: Pluripotent stem cells have been used by various researchers to differentiate and characterize endothelial cells (ECs) and vascular smooth muscle cells (VSMCs) for the clinical treatment of vascular injuries. Studies continue to differentiate and characterize the cells with higher vascularization potential and low risk of malignant transformation to the recipient. Unlike previous studies, this research aimed to differentiate induced pluripotent stem (iPS) cells into endothelial progenitor cells (EPCs) and VSMCs using a step-wise technique. This was achieved by elucidating the spatio-temporal expressions of the stage-specific genes and proteins during the differentiation process. The presence of highly expressed oncogenes in iPS cells was also investigated during the differentiation period., Methods: Induced PS cells were differentiated into lateral mesoderm cells (Flk1 + ). The Flk1 + populations were isolated on day 5.5 of the mesodermal differentiation period. Flk1 + cells were further differentiated into EPCs and VSMCs using VEGF 165 and platelet-derived growth factor-BB (PDGF-BB), respectively, and then characterized using gene expression levels, immunocytochemistry (ICC), and western blot (WB) methods. During the differentiation steps, the expression levels of the marker genes and proto-oncogenic Myc and Klf4 genes were simultaneously studied., Results: The optimal time for the isolation of Flk1 + cells was on day 5.5. EPCs and VSMCs were differentiated from Flk1 + cells and characterized with EPC-specific markers, including Kdr, Pecam1, CD133, Cdh5, Efnb2, Vcam1 ; and VSMC-specific markers, including Acta2, Cnn1, Des, and Myh11 . Differentiated cells were validated based on their temporal gene expressions, protein synthesis, and localization at certain time points. Significant decreases in Myc and Klf4 gene expression levels were observed during the EPCs and VSMC differentiation period., Conclusion: EPCs and VSMCs were successfully differentiated from iPS cells and characterized by gene expression levels, ICC, and WB. We observed significant decreases in oncogene expression levels in the differentiated EPCs and VSMCs. In terms of safety, the described methodology provided a better safety margin. EPCs and VSMC obtained using this method may be good candidates for transplantation and vascular regeneration., Competing Interests: The authors declare no conflicts of interest., (© 2023 The Author(s).)

Objective: Extracorporeal membrane oxygenation is a life-saving treatment for patients with circulatory and respiratory failure refractory to standard therapy. However, safe and timely patient transport to the referral extracorporeal membrane oxygenation center is critical for better patient outcomes in patients with acute cardiogenic shock. This study aimed to describe children's features who were transferred to our center under extracorporeal membrane oxygenation by aircraft/ground vehicle and demonstrated the importance of extracorporeal cardiopulmonary resuscitation for transported children., Materials and Methods: We report the first Turkish pediatric case series of patients with acute cardiogenic shock transported by aircraft and ground ambulances on extracorporeal membrane oxygenation support to a referral extracorporeal membrane oxygenation center between January 2016 and January 2021., Results: Overall, 6 patients on venoarterial extracorporeal membrane oxygenation support were transported by aircraft and ground vehicles to our pediatric intensive care unit. Transport was achieved by fixed-wing aircraft in 5 patients and commercial aircraft in 1. Our mobile extracorporeal membrane oxygenation team cannulated 3 patients, and 3 patients were cannulated by the team at the hospital they applied to. The median age was 112 (range: 14-204) months and the median weight was 28.6 kg (range: 8.6-57.2 kg). The etiology of acute cardiogenic shock was fulminant myocarditis in 4 patients, dilated cardiomyopathy in 1, and transposition of great arteries and atrial flutter in 1. The median distance of travel for the patients to our hospital was 618 (407-955) km. No adverse events were detected during aircraft or ground vehicle transport., Conclusion: Mobile pediatric extracorporeal membrane oxygenation transport teams may provide safe aircraft and ground vehicle transportation in high-risk patients with acute cardiogenic shock bridging to survival or long-term circulatory support.

Background: We aimed at evaluating acute neurologic complications (ANC) and clinical outcome at a 2-year follow-up in children after extracorporeal membrane oxygenation (ECMO)., Methods: We conducted a single-center, retrospective review of our patient cohort aged between 1 month and 18 years at the time of ECMO support (between June 2014 to January 2017). Outcome analysis included ANC and their clinical consequences.The Pediatric Overall Performance Category (POPC) and Pediatric Cerebral Performance Category (PCPC) were used for neurologic assessment performed at discharge from the hospital and at 2nd year follow-up., Results: There were 35 children who required ECMO. The median ECMO time was 9 days (range 2-32 days). Decannulation from ECMO was achieved in 68.6% of patients, and overall, 42.8% survived (15 patients), The incidence of ANC in the surviving patients was 40% (6 children). ANC were intracranial hemorrhage, seizures, cerebral infarction, which occurred in one, two and three of the 15 surviving patients respectively (6.6, 13.3 and 20%). A higher rate of organ failure was related to death (p=0.043), whereas duration on ECMO was a risk factor for the development of ANC (p<0.05). At hospital discharge, the 14 patients evaluated had normal development or -mild disability in 73.2%, and at the 2-year follow-up, 93.4% had these scores., Conclusion: Children who receive ECMO have a risk to develop ANC, which was related to the length of ECMO treatment, while survival was related to less organ failure, Long-term neurological outcome was good in our patient cohort., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background: In this study, we aimed to compare ultrasoundguided versus bronchoscopy-guided percutaneous dilatational tracheostomy outcomes in critically ill adult patients undergoing a median sternotomy., Methods: Between January 2015 and December 2020, a total of 54 patients (17 males, 37 females; mean age: 54.9±13.1 years; range, 39 to 77 years) who underwent elective ultrasound- or bronchoscopy-guided percutaneous dilatational tracheostomy after a median sternotomy were included. We compared the ultrasound-guided group (n=25) with the bronchoscopy-guided group (n=29) regarding all-cause mortality and complications. Safety assessments included major and minor bleeding, procedural hypoxic or hypotensive event, cardiac dysrhythmias, tracheal injury, damage to adjacent structures, and requirement of conversion to open surgical tracheostomy., Results: No tracheostomy procedure-related death was observed in either group. The median time for tracheostomy was 13 (range, 8 to 17) min in the ultrasound-guided group and 10 (range, 7 to 15) min in the bronchoscopy-guided group (p=0.387). There was no need for conversion between the two methods or conversion to surgical tracheostomy for any patient. The overall complication rates did not significantly differ between the groups (p=0.15)., Conclusion: Ultrasound-guided percutaneous dilatational tracheostomy can be safely performed in patients undergoing sternotomy. Complication rates of the procedure are similar to those guided with bronchoscopy., Competing Interests: Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article., (Copyright © 2021, Turkish Society of Cardiovascular Surgery.)

Objectives: Transcriptomics of atrial fibrillation (AFib) in the setting of chronic primary mitral regurgitation (MR) remains to be characterized. We aimed to compare the gene expression profiles of patients with degenerative MR in AFib and sinus rhythm (SR) for a clearer picture of AFib pathophysiology., Methods: After transcriptomic analysis and bioinformatics ( n = 59), differentially expressed genes were defined using 1.5-fold change as the threshold. Additionally, independent datasets from GEO were included as meta-analyses., Results: QRT-PCR analysis confirmed that AFib persistence was associated with increased expression molecular changes underlying a transition to heart failure ( NPPB , P = 0.002; ANGPTL2 , P = 0.002; IGFBP2 , P = 0.010), structural remodeling including changes in the extracellular matrix and cellular stress response ( COLQ , P = 0.003; COMP , P = 0.028; DHRS9 , P = 0.038; CHGB , P = 0.038), and cellular stress response ( DNAJA4 , P = 0.038). Furthermore, AFib persistence was associated with decreased expression of the targets of structural remodeling ( BMP7 , P = 0.021) and electrical remodeling ( CACNB2 , P = 0.035; MCOLN3 , P = 0.035) in both left and right atrial samples. The transmission electron microscopic analysis confirmed ultrastructural atrial remodeling and autophagy in human AFib atrial samples., Conclusions: Atrial cardiomyocyte remodeling in persistent AFib is closely linked to alterations in gene expression profiles compared to SR in patients with primary MR. Study findings may lead to novel therapeutic targets. This trial is registered with ClinicalTrials.gov identifier: NCT00970034., Competing Interests: The authors declare no competing interests., (Copyright © 2021 Günseli Çubukçuoğlu Deniz et al.)

Background/aim: Extracorporeal cardiopulmonary resuscitation (ECPR) is defined as the venoarterial extracorporeal membrane oxygenation (VA-ECMO) support in a patient who experienced a sudden pulseless condition attributable to cessation of cardiac mechanical activity and circulation. We aimed to evaluate the clinical outcomes of our ECPR experience in a pediatric patient population., Materials and Methods: Between September 2014 and November 2017, 15 children were supported with ECPR following in-hospital cardiac arrest (IHCA) in our hospitals. VA-ECMO setting was established for all patients. Pediatric cerebral performance category (PCPC) scales and long-term neurological prognosis of the survivors were assessed., Results: The median age of the study population was 60 (4–156) months. The median weight was 18 (4.8–145) kg, height was 115 (63–172) cm, and body surface area was 0.73 (0.27–2.49) m2. The cause of cardiac arrest was a cardiac and circulatory failure in 12 patients (80%) and noncardiac causes in 20%. Dysrhythmia was present in 46%, septic shock in 13%, bleeding in 6%, low cardiac output syndrome in 13%, and airway disease in 6% of the study population. Median low-flow time was 95 (range 20–320) min. Central VA- ECMO cannulation was placed in only 2 (13.3%) cases. However, the return of spontaneous circulation (ROSC) was obtained in 10 (66.6%) patients, and 5 (50%) of them survived. Overall, 5 patients were discharged from the hospital. Finally, survival following ECPR was 33.3%, and all survivors were neurologically intact at hospital-discharge., Conclusion: ECPR can be a life-saving therapeutic strategy using a promising technology in the pediatric IHCA population. Early initiation and a well-coordinated, skilled, and dedicated ECMO team are the mainstay for better survival rates., (This work is licensed under a Creative Commons Attribution 4.0 International License.)

Abstract: Broad and deep perianal wounds are challenging in both adult and pediatric ICUs. These wounds, if contaminated with gastrointestinal flora, can cause invasive sepsis and death, and recovery can be prolonged. Controlling the source of infection without diverting stool from the perianal region is complicated. The option of protective colostomy is not well-known among pediatric critical care specialists, but it can help patients survive extremely complicated critical care management. These authors present three critically ill children who required temporary protective colostomy for perianal wounds because of various clinical conditions. Two patients were treated for meningococcemia, and the other had a total artificial heart implantation for dilated cardiomyopathy. There was extensive and profound tissue loss in the perianal region in the patients with meningococcemia, and the patient with cardiomyopathy had a large pressure injury. Timely, transient, protective colostomy was beneficial in these cases and facilitated the recovery of the perianal wounds. Temporary diverting colostomy should be considered as early as possible to prevent fecal transmission and accelerate perianal wound healing in children unresponsive to local debridement and critical care., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Our goal was to compare the haemodynamic effects of different mechanical left ventricular (LV) unloading strategies and clinical outcomes in patients with refractory cardiogenic shock supported with venoarterial extracorporeal membrane oxygenation (VA-ECMO)., Methods: A total of 448 patients supported with VA-ECMO for refractory cardiogenic shock between 1 March 2015 and 31 January 2020 were included and analysed in a single-centre, retrospective case-control study. Fifty-three patients (11.8%) on VA-ECMO required LV unloading. Percutaneous balloon atrial septostomy (PBAS), intra-aortic balloon pump (IABP) and transapical LV vent (TALVV) strategies were compared with regards to the composite rate of death, procedure-related complications and neurological complications. The secondary outcomes were reduced pulmonary capillary wedge pressure, pulmonary artery pressure, central venous pressure, left atrial diameter and resolution of pulmonary oedema on a chest X-ray within 48 h., Results: No death related to the LV unloading procedure was detected. Reduction in pulmonary capillary wedge pressure was highest with the TALVV technique (17.2 ± 2.1 mmHg; P < 0.001) and was higher in the PBAS than in the IABP group; the difference was significant (9.6 ± 2.5 and 3.9 ± 1.3, respectively; P = 0.001). Reduction in central venous pressure with TALVV was highest with the other procedures (7.4 ± 1.1 mmHg; P < 0.001). However, procedure-related complications were significantly higher with TALVV compared to the PBAS and IABP groups (50% vs 17.6% and 10%, respectively; P = 0.015). We observed no significant differences in mortality or neurological complications between the groups., Conclusions: Our results suggest that TALVV was the most effective method for LV unloading compared with PBAS and IABP for VA-ECMO support but was associated with complications. Efficient LV unloading may not improve survival., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

The document is prepared to guide the members of the The Turkish Society of Cardiovascular Surgery (TSCVS) and other extracorporeal membrane oxygenation (ECMO) centers worldwide to share experiences in using ECMO in COVID-19 pandemic., Competing Interests: Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article., (Copyright © 2020, Turkish Society of Cardiovascular Surgery.)

Infective endocarditis (IE) is rare, but associated with significant morbidity and mortality rates. Estimates of the incidence of IE in Turkey are compromised by the absence of population-based prospective studies. Due to the frequent presence of predisposing cardiac conditions and higher rates of nosocomial bacteremia in highrisk groups, the incidence of IE is expected to be higher in Turkey. Additionally, while IE generally affects older people in developed countries, it still affects young people in Turkey. In order to reduce the mortality and morbidity, it is critical to diagnose the IE to determine the causative agent and to start treatment rapidly. However, most of the patients cannot be diagnosed in their first visits, about half of them can be diagnosed after three months, and the disease often goes unnoticed. In patients diagnosed with IE, the rate of identification of causative organisms is significantly lower in Turkey than in developed countries. Furthermore, most of the centers do not perform some essential microbiological diagnostic tests as a routine practice. Some antimicrobials that are recommended as the first-line of treatment for IE, particularly antistaphylococcal penicillins, are not available in Turkey. These problems necessitate reviewing the epidemiological, laboratory, and clinical characteristics of IE in our country, as well as the current information about its diagnosis, treatment, and prevention together with local data. Physicians can follow patients with IE in many specialties. Diagnosis and treatment processes of IE should be standardized at every stage so that management of IE, a setting in which many physicians are involved, can always be in line with current recommendations. Study Group for Infective Endocarditis and Other Cardiovascular Infections of the Turkish Society of Clinical Microbiology and Infectious Diseases has called for collaboration of the relevant specialist organizations to establish a consensus report on the diagnosis, treatment, and prevention of IE in the light of current information and local data in Turkey., Competing Interests: Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article., (Copyright © 2020, Turkish Society of Cardiovascular Surgery.)

Excitation-contraction coupling in normal cardiac function is performed with well balanced and coordinated functioning but with complex dynamic interactions between functionally connected membrane ionic currents. However, their genomic investigations provide essential information on the regulation of diseases by their transcripts. Therefore, we examined the gene expression levels of the most important voltage-gated ionic channels such as Na + -channels (SCN5A), Ca 2+ -channels (CACNA1C and CACNA1H), and K + -channels, including transient outward (KCND2, KCNA2, KCNA5, KCNA8), inward rectifier (KCNJ2, KCNJ12, KCNJ4), and delayed rectifier (KCNB1) in left ventricular tissues from either ischemic or dilated cardiomyopathy (ICM or DCM). We also examined the mRNA levels of ATP-dependent K + -channels (KCNJ11, ABCC9) and ERG-family channels (KCNH2). We further determined the mRNA levels of ryanodine receptors (RyR2; ARVC2), phospholamban (PLB or PLN), SR Ca 2+ -pump (SERCA2; ATP2A1), an accessory protein FKBP12 (PPIASE), protein kinase A (PPNAD4), and Ca 2+ /calmodulin-dependent protein kinase II (CAMK2G). The mRNA levels of SCN5A, CACNA1C, and CACNA1H in both groups decreased markedly in the heart samples with similar significance, while KvLQT1 genes were high with depressed Kv4.2. The KCNJ11 and KCNJ12 in both groups were depressed, while the KCNJ4 level was significantly high. More importantly, the KCNA5 gene was downregulated only in the ICM, while the KCNJ2 was upregulated only in the DCM. Besides, mRNA levels of ARVC2 and PLB were significantly high compared to the controls, whereas others (ATP2A1, PPIASE, PPNAD4, and CAMK2G) were decreased. Importantly, the increases of KCNB1 and KCNJ11 were more prominent in the ICM than DCM, while the decreases in ATP2A1 and FKBP1A were more prominent in DCM compared to ICM. Overall, this study was the first to demonstrate that the different levels of changes in gene profiles via different types of cardiomyopathy are prominent particularly in some K + -channels, which provide further information about our knowledge of how remodeling processes can be differentiated in HF originated from different pathological conditions.

Purpose of Review: Right heart failure (RHF) following left ventricular assist device implantation (LVAD) remains the primary cause of postoperative mortality and morbidity, and prediction of RHF is the main interest of the transplantation community. In this review, we outline the role and impact of right ventricular strain in the evaluation of the right ventricle function before LVAD implantation., Recent Findings: Accumulating data suggest that measurement of right ventricular longitudinal strain (RVLS) has a critical role in predicting RHF preoperatively and may improve morbidity and mortality following LVAD implantation. However, the significant intraobserver, interobserver variability, the lack of multicenter, prospective studies, and the need for a learning curve remain the most critical limitations in the clinical practice at present. This review highlighted the importance of right ventricular strain in the diagnosis of RHF preoperatively and revealed that RVLS might have a crucial clinical measurement for the selection and management of LVAD patients in the future with the more extensive multicenter studies.

Several indications for sutureless aortic valve replacement (SU-AVR) have been a matter of debate. We evaluated our experience with Perceval-S (LivaNova group, Saluggia, Italy) SU-AVR in patients with severe aortic stenosis (AS) involving bicuspid aortic valve (BAV), even though presence of BAV is still considered to be a contraindication for sutureless valves. From January 2013 through March 2018, 13 patients with severe AS involving BAV underwent SU-AVR with the Perceval-S (LivaNova group, Saluggia, Italy) prosthesis in a single center. Preoperative evaluation included coronary catheterization and multisliced computerized tomography was performed in all patients. Three-dimensional transthoracic echocardiography was used to evaluate for obtaining the anatomy and phenotype of BAV. Minimally invasive approach through right anterior thoracotomy from third intercostal space was performed for all patients. The mean age was 72.8 ± 2.26 years ranging from 70 to 77, and 53.8% (n = 7) were male. The mean aortic valve gradient decreased from 46.4 ± 13.8 to 13.6 ± 4.4 mmHg postoperatively. The mean aortic valve area increased from 0.69 ± 0.22 to 1.81 ± 0.38 cm 2 . There was no in-hospital mortality. One patient (7.6%) had third-degree atrioventricular block requiring permanent pacemaker implantation. Mean follow-up was 15.1 ± 6.3 months (maximum 2 years). No major paravalvular leakage or valve migration occurred postoperatively. This study shows that SU-AVR is a technically feasible and safe procedure in patients with severe AS and BAV with acceptable good surgical outcomes. Presence of BAV in AS should not be considered a contraindication to Perceval-S prosthesis (LivaNova group, Saluggia, Italy)., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Competing Interests: Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Objectives: Right heart failure (RHF) is an important prognostic factor in continuous-flow left ventricular assist device (LVAD) therapy. We aimed to assess the clinical variables associated with RHF after LVAD implantation and to compare their performance against currently available RHF predictive scoring systems., Methods: The study cohort comprised 57 patients who underwent LVAD therapy between January 2012 and May 2018 in our centre. The mean age of the patients was 39.9 ± 18.3 years, and 43 (81.1%) of them were men. Thirty-eight patients (66.6%) were in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile I or II. The study cohort was divided into the patients with RHF postoperatively (n = 20, 35.1%) and without RHF (n = 37, 64.9%)., Results: Independent predictors for RHF were preoperative right ventricular ejection fraction <25% [odds ratio (OR) 4.68, 95% confidence interval (CI) 1.41-15.5; P = 0.01], right ventricular stroke work index <400 mmHg ml-1 (OR 3.73, 95% CI 1.01-13.7; P = 0.04), right ventricular outflow tract systolic excursion <7 mm (OR 1.55, 95% CI 0.31-0.84; P = 0.002), right ventricular outflow tract fractional shortening <15% (OR 1.62, 95% CI 0.34-0.78; P = 0.02), right ventricular free wall longitudinal strain ≤19% (OR 3.13, 95% CI 1.01-2.43; P = 0.003), right ventricular fractional area change <27% (OR 3.71, 95% CI 1.15-11.9; P = 0.02) and prealbumin <14 mg/dl (OR 3.45, 95% CI 1.07-11.03; P = 0.03). Modest diagnostic performance for RHF was detected in 4 of 7 validated scoring systems with resulting area under the curve values of 0.70 (95% CI 0.55-0.84; P = 0.001) for the Seattle Heart Failure Model; 0.68 (95% CI 0.49-0.81, P = 0.03) for the Fitzpatrick's; 0.68 (95% CI 0.53-0.83, P = 0.028) for the acute physiology and chronic health evaluation (APACHE) II; and 0.66 (95% CI 0.50-0.82, P = 0.04) for the model for end-stage liver disease scoring systems. However, we found best discrimination performance of the score with a resulting area under the curve value of 0.94 (95% CI 0.55-0.89, P = 0.03) for right ventricular free wall longitudinal strain ≥-15.5% and 0.82 for right ventricular stroke work index <400 mmHg ml-1 m-2 in predicting RHF., Conclusions: Right ventricular free wall longitudinal strain ≥-15.5% and right ventricular stroke work index <400 mmHg ml-1 m-2 were independent predictors of RHF following LVAD implantation. Currently available prediction risk scores had the modest power of accuracy in the low INTERMACS profile Turkish population., (© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: All innovations in cardiac surgery provide us with new techniques to perform surgery through smaller incisions with less invasive and best cosmetic results. After promising results in minimally invasive cardiac surgery (MICS), pain and cosmetic appearance became important end points, especially for female patients. In the current study, we intended to evaluate the surgical results and cosmetic satisfaction with the periareolar and submammary incision types in cardiac surgery., Methods: Ninety-four female patients underwent MICS between July 2013 and March 2018. MICS was performed in 62 patients via periareolar incision and in 32 patients via submammarian incision. We investigated the incision size, wound infection, pain levels by using a postoperative standard pain-level questionnaire, the postoperative scar size, and patient satisfaction using a postoperative patient questionnaire., Results: Periareolar incision size was smaller than the submammary incision (Group A: 5.6±0.6 vs. Group B: 6.7±0.8, p=0.001). Four patients from Group B had superficial wound infection (p=0.01). Patients who underwent MICS via periareolar incision and submammary incision had similar pain level (p=0.2). The scar tissue was smaller in size and postoperatively healed better in the following days for the patients with periareolar incision due to the elastic structure of breast tissue. (Group A: 4.3±0.4 vs. Group B: 5.3±0.2, p=0.001)., Conclusion: Our study suggests that the periareolar approach would be more aesthetic, show better healing, and have a smaller scar size in female patients.

We report a case of 53-year-old woman with the parathyroid adenoma (PA) located in the aortopulmonary window with an aberrant right subclavian artery. Her preoperative calcium level was 11.3 mg/dL (reference range = 8.8-10.6 mg/dL). The parathyroid hormone level was significantly elevated at 127.4 pg/mL (reference range = 12-88 pg/mL) as measured on immunoradiometric assay. Dual-phase technetium-99m-labeled sestamibi parathyroid scintigraphy and fluorine-18 F-fluorocholine positron emission tomography/computed tomography revealed a mediastinal tumor measuring 3 × 5 × 6 mm located anterolateral to the aortopulmonary window. Minimally invasive removal of PA was performed through 3.5-cm reverse J-shaped partial upper sternotomy to the third intercostal space. Postoperative recovery was uneventful, and serum calcium and parathyroid hormone levels normalized within 24 hours of surgery. Our case represents the rare occurrence of a mediastinal PA associated with aberrant right subclavian artery treated with targeted minimally invasive approach using different imaging modalities including technetium-99m-sestamibi scintigraphy and fluorine-18 F-fluorocholine positron emission tomography/computed tomography, and intraoperative use of gamma probe for precise localization PA.

Background: The aim of this study was to evaluate the clinical outcomes of tricuspid valve repair using aortic cross-clamping versus using beating heart surgery., Methods: A total of 208 patients (67 males, 141 females; mean age 61.5±9.2 years; range, 29 to 81 years) who underwent concomitant cardiac surgery and tricuspid valve repair between January 2007 and January 2016 at a single center were included. Two surgical strategies for tricuspid valve repair with aortic cross-clamping (n=102) or on beating heart (n=106) were compared. Primary endpoints were in-hospital mortality and the rate of permanent pacemaker placement after surgery. Secondary endpoints were cross-clamp and cardiopulmonary bypass times, postoperative inotropic support, temporary pacemaker requirement, and residual tricuspid regurgitation at discharge and at one year., Results: Overall hospital mortality was 7% (n=14) (cross-clamping 7% vs. beating heart 7%; p>0.05). The mean cross-clamp and cardiopulmonary bypass times were significantly longer in the aortic cross-clamping group (p=0.0001). Also, a higher number of patients in this group needed inotropic support (78/102) than the beating heart group (57/106) (p<0.05). The rate of postoperative left bundle branch block was higher in the cross-clamping group (14% vs. 5%, respectively; p<0.05). The rate of permanent pacemaker placement was also significantly higher in the cross-clamping group than the beating heart group (11.8% vs. 2.8%, respectively; p<0.05). At discharge, residual >2 tricuspid regurgitation was more commonly seen in the cross-clamping group (16% vs. 3%, respectively; p=0.0023). At one year of follow-up, residual >2 tricuspid regurgitation was present in 22 patients (23%) in the aortic crossclamping group and in eight patients (8%) in the beating heart group (p=0.0048)., Conclusion: Tricuspid valve repair on beating heart offers less inotropic support and a lower rate of postoperative permanent pacemaker placement requirement and residual tricuspid regurgitation, although both techniques yield similar postoperative clinical outcomes. These results support the use of tricuspid valve repair on a beating heart in concomitant left-sided valvular heart surgery., Competing Interests: Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article., (Copyright © 2018, Turkish Society of Cardiovascular Surgery.)

Objectives: Sutureless aortic valve replacement (SU-AVR) is an alternative technique to standard aortic valve replacement. We evaluated our experience with the Perceval SU-AVR with concomitant mitral valve surgery, with or without tricuspid valve surgery, and aimed to discuss the technical considerations., Methods: From January 2013 through June 2016, 30 patients with concomitant severe mitral valve disease, with or without tricuspid valve disease, underwent SU-AVR with the Perceval prosthesis in a single center., Results: The mean age was 73.0 ± 6.6 years, ranging from 63 to 86 years, and 60% (n = 18) were male. Mean logistic EuroScore of the study cohort was 9.8 ± 4.6. Concomitant procedures consisted of mitral valve repair (n = 8, 26.6%), mitral valve replacement (n = 22, 73.3%), tricuspid valve repair (n = 18, 60%), tricuspid valve replacement (n = 2, 6.6%), and cryoablation for atrial fibrillation (n = 21, 70%). Median prosthesis size was 25 mm (large size). At 1 year, there were 2 deaths from noncardiac causes. One patient (3.3%) had third-degree atrioventricular block requiring permanent pacemaker implantation. Three patients (10%) had intraoperative supra-annular malpositioning of the aortic prosthesis, which was safely removed and reimplanted in all cases. Mean follow-up was 18 ± 4.5 for months (maximum 3 years). During the postoperative period, sinus rhythm restoration rate in patients who underwent the cryo-maze procedure was 76.1% (n = 16) at discharge. There was no structural valve deterioration or migration of the prosthesis at follow-up., Conclusions: Perceval SU-AVR is a technically feasible and safe procedure in patients with severe aortic stenosis with good results even in the presence of multivalvular disease and atrial fibrillation surgery., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The aim of this study was to investigate lead endocarditis-related tricuspid valve regurgitation, to identify underlying causes, and to report our surgical approaches to tricuspid valve endocarditis., Methods: Between March 2010 and August 2016, medical records of a total of 43 patients (23 males, 20 females; mean age: 63.2±13.6 years; range 48 to 72 years) who underwent tricuspid valve surgery for severe tricuspid regurgitation caused by lead endocarditis, which was previously placed as an implantable cardiac electronic device were reviewed. We removed all systems including infected leads and generators, revised infected wounds and tissues, performed tricuspid valve surgery for lead endocarditis, and applied long-term intravenous antibiotic regimen for the culprit agent, as confirmed by the culture., Results: Of 43 patients, 18 underwent tricuspid valve repair and 25 underwent tricuspid valve replacement for lead endocarditisrelated severe tricuspid valve regurgitation. During followup (range, 2 to 62 months), two patients required temporary mechanical support due to postoperative acute right heart failure, while eight patients died due to sepsis (n=6; 14%) and stroke (n=2; 4.6%) in the early postoperative period. The remaining patients showed significant improvement in signs and symptoms of heart failure., Conclusion: Our study results suggest that incompetent experience and inaccurate decision for valve repair may result in delayed valve replacement and prolonged operation time., Competing Interests: Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article., (Copyright © 2018, Turkish Society of Cardiovascular Surgery.)

Zn 2+ -homoeostasis including free Zn 2+ ([Zn 2+ ] i ) is regulated through Zn 2+ -transporters and their comprehensive understanding may be important due to their contributions to cardiac dysfunction. Herein, we aimed to examine a possible role of Zn 2+ -transporters in the development of heart failure (HF) via induction of ER stress. We first showed localizations of ZIP8, ZIP14 and ZnT8 to both sarcolemma and S(E)R in ventricular cardiomyocytes (H9c2 cells) using confocal together with calculated Pearson's coefficients. The expressions of ZIP14 and ZnT8 were significantly increased with decreased ZIP8 level in HF. Moreover, [Zn 2+ ] i was significantly high in doxorubicin-treated H9c2 cells compared to their controls. We found elevated levels of ER stress markers, GRP78 and CHOP/Gadd153, confirming the existence of ER stress. Furthermore, we measured markedly increased total PKC and PKCα expression and PKCα-phosphorylation in HF. A PKC inhibition induced significant decrease in expressions of these ER stress markers compared to controls. Interestingly, direct increase in [Zn 2+ ] i using zinc-ionophore induced significant increase in these markers. On the other hand, when we induced ER stress directly with tunicamycin, we could not observe any effect on expression levels of these Zn 2+ transporters. Additionally, increased [Zn 2+ ] i could induce marked activation of PKCα. Moreover, we observed marked decrease in [Zn 2+ ] i under PKC inhibition in H9c2 cells. Overall, our present data suggest possible role of Zn 2+ transporters on an intersection pathway with increased [Zn 2+ ] i and PKCα activation and induction of HF, most probably via development of ER stress. Therefore, our present data provide novel information how a well-controlled [Zn 2+ ] i via Zn 2+ transporters and PKCα can be important therapeutic approach in prevention/treatment of HF., (© 2018 The Authors. Journal of Cellular and Molecular Medicine published by John Wiley & Sons Ltd and Foundation for Cellular and Molecular Medicine.)

Background: Liver resection for intrahepatic cholangiocarcinoma (ICC) with invasion of the inferior vena cava (IVC) and hepatic veins (HV) is a challenging procedure., Case Presentation: We report a case of a 63-year-old woman with a 6-cm, centrally located liver mass. Her biochemistry results were normal except for a Ca19-9 level of 1199 U/ml. The liver biopsy was consistent with ICC and 60% macrosteatosis. Abdominal CT scans revealed a large central mass invading the left HV, middle HV and right HV, infringing on their junction with the vena cava. An operation was planned using a 3-dimensional (3D) computer simulation model using dedicated software. We also describe a novel veno-portal-venous extracorporeal membrane oxygenation (VPV-ECMO) support with in-situ hypothermic perfusion (IHP) during this procedure. We aimed to perform an extended left hepatectomy and reconstruct 3 right HV orifices with an interposition jump graft to the IVC with total vascular exclusion (TVE) and IHP A supplemental video describing the preoperative planning, the operative procedure with the postoperative follow-up in detail is presented. After the patient was discharged, she developed a hepatic venous outflow obstruction 3 months postoperatively, which was effectively managed with hepatic venous stenting by interventional radiology. She is currently symptom free and without tumour recurrence at the 1-year follow-up., Conclusions: This report demonstrates that extended left hepatectomy for IHC with IHP and VPV-ECMO is safe and feasible under the supervision of a highly experienced team.