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Incidence and clinical implications of aortic root thrombosis in LVAD patients: A single-center experience - Turkish Journal of Thoracic and Cardiovascular Surgery

Background/Aims: In this study, the results of patients who had orthotopic heart transplantation (OHT) in acute rejection who admitted to our clinic with decompensated heart failure and who could not undergo endomyocardial biopsy (EMB) were evaluated. Methods: The study included 27 patients who underwent OHT in our clinic between December 1998 and November 2021, who admitted with acute rejection causing decompensated heart failure during follow-up, and who could not undergo EMB and administered IV pulse steroid plus plasmapheresis. Demographics of patients, peri-treatment left ventricular functions, survival rates and causes of mortality were analyzed. Results: 19 (70.4%) were male and mean age was 28.7 ± 14.7 (range: 3-54). After OHT, overall survival rates were 92.6%, 77.6%, and 69.4% at 1st, 3rd and 5th year respectively. During the follow-up, the survival rates of patients who presented with decompensated heart failure and given pulse steroid plus plasmapheresis were 70.4%, 58.8%, and 53.4% at 1st, 3rd and 5th year respectively after plasmapheresis. Median rejection time after transplant was 19 months (range 0-113 months). Pre-, and post-treatment left ventricle ejection fractions were 25.11% ± 11.1%, and 52.14% ± 13.4% respectively (p<0.05). The leading causes of mortality were pneumonia causing sepsis (5/13 patients). Conclusions: In acute rejection patients with decompensated heart failure in whom EMB is not possible, administration of plasmapheresis in addition to IV pulse steroid therapy may have a positive effect on survival in this patient group. Özet Amaç: Bu çalışmada ortotopik kalp nakli (OHT) yapılan, takip sırasında dekompanze kalp yetmezliğine neden olan akut rejeksiyon ile kliniğimize başvuran ve endomiyokardiyal biyopsi (EMB) yapılamayan hastaların sonuçları değerlendirildi. Yöntemler: Çalışmaya Aralık 1998-Kasım 2021 tarihleri arasında kliniğimizde OHT yapılıp, takip sırasında dekompanze kalp yetmezliğine neden olan akut rejeksiyon ile başvuran ve EMB uygulanamayan, IV pulse steroid + plazmaferez uygulanan 27 hasta dahil edildi. Hastaların demografik özellikleri, tedavi öncesi sol ventrikül fonksiyonları, sağkalım oranları ve mortalite nedenleri analiz edildi. Bulgular: Hastaların 19'u (%70.4) erkekti ve yaş ortalaması 28.7 ± 14.7 (3-54) idi. OHT sonrası genel sağkalım oranları 1., 3. ve 5. yılda sırasıyla %92.6, %77.6 ve %69.4 idi. İzlemde dekompanze kalp yetmezliği ile başvuran ve pulse steroid + plazmaferez uygulanan hastaların plazmaferez sonrası 1., 3. ve 5. yılda sağkalım oranları sırasıyla %70.4, %58.8 ve %53.4 idi. Nakil sonrası median rejeksiyon süresi 19 aydı (0-113 ay). Tedavi öncesi ve sonrası sol ventrikül ejeksiyon fraksiyonları sırasıyla %25.11±%11.1 ve %52.14±%13.4 idi (p<0.05). Mortalitenin önde gelen nedeni ise sepsise neden olan pnömoni (5/13 hasta) idi. Sonuç: EMB'nin yapılmasının mümkün olmadığı dekompanze kalp yetmezliği olan akut rejeksiyon hastalarında, IV pulse steroid tedavisine ek olarak plazmaferez uygulanması sağkalımı olumlu etkileyebilir.

Heart failure (HF) is a growing public health problem with high morbidity and mortality. Recently, angiotensin receptor neprilysin inhibitor (ARNi) has emerged as a promising treatment for HF with reduced ejection fraction (HFrEF). Here, we shared our experience with the use of ARNi in HFrEF from multiple centers in Turkey. The ARNi-TR is a multicenter, noninterventional, retrospective, observational study. Overall, 779 patients with HF from 22 centers in Turkey who were prescribed sacubitril/valsartan were examined. Initial clinical status, biochemical and echocardiographic parameters, and New York Heart Association functional class (NYHA-FC) values were compared with follow-up values after 1 year of ARNi use. In addition, the effect of ARNi on number of annual hospitalizations was investigated, and the patients were divided into 2 groups, depending on whether ARNi was initiated at hospitalization or under outpatient clinic control. N-terminal pro-brain natriuretic peptide (NT-proBNP), left-ventricle ejection fraction (LV-EF), and NYHA-FC values improved significantly in both groups (all parameters, p<0.001) within 1-year follow-up. In both groups, a decrease in hemoglobin A1c (HbA1c) values was observed in ARNi use (p<0.001), and a decrease in daily diuretic doses and hospitalizations owing to HF were observed after ARNi use (all comparisons, p<0.001). Hypertension (16.9%) was the most common side effect in patients using ARN. The ARNi-TR study offers comprehensive real-life data for patients using ARNi in Turkey. The use of ARNi has shown significant improvements in FC, NT-proBNP, HbA1c levels, and LV-EF. Likewise, reductions in the number of annual hospitalizations and daily furosemide doses for HF were seen in this study.

The aim of the study is to compare outcomes of the patients who underwent HeartMate3 (HM3) implantation with conventional sternotomy (CS) and minimally invasive thoracotomy technique (MILT). From June 2013 to April 2019, 50 patients who underwent isolated HM3 implantation were included. Patients were divided into two groups according to the operative technique; of 50 patients, 28 were implanted with CS and 22 with MILT. All patients were evaluated for mortality, need of inotrope, blood product transfusion, intensive care unit stay, time on mechanical ventilation, and postoperative right ventricular failure. Primary outcomes were early mortality and occurrence of adverse events. Patients characteristics were similar; preoperative central venous pressure (CVP) and the ratio of CVP to pulmonary capillary wedge pressure (CVP/PCWP) were significantly higher in the MILT group versus the CS group (p < 0.05). Intensive care unit stay was significantly shorter in the MILT group (p < 0.05). Incidence of bleeding requiring exploratory sternotomy and postoperative drainage on the first postoperative day were statistically higher in the CS group (p < 0.05). Right ventricular failure was higher in the CS group but was not statistically significant (p = 0.4). There was no significant difference in long-term adverse events. The Kaplan–Meier survival analysis showed no difference between the groups (p = 0.66). The HM3 assist system can be successfully implanted with the MILT technique, which has proved to be safe and reproducible and yields good clinical outcomes.

Continuous‐flow left ventricular assist devices (LVADs) reduce peak systolic flow, increase diastolic flow, and eliminate pulsatility of circulation. Altered blood flow may lead to a change in end‐organ perfusion. Analysis of the flow dynamics of the arteries of end‐organs, such as the brain, may indicate whether an organ is perfused sufficiently. The aim of this study is to evaluate and identify the flow pattern changes of carotid (CA) and middle cerebral arteries (MCA) in LVAD patients and to compare with heart failure patients and healthy volunteers. Eighty‐nine individuals were included in this cross‐sectional study. Participants were divided into three groups: LVAD patients (n=31), heart failure patients (n=26), and healthy volunteers (n=27). Carotid and transcranial Doppler ultrasonography were performed for all study groups for peak systolic velocity (PSV), end‐diastolic velocity (EDV), pulsatility (PI), and resistive (RI) indices of CA and MCA. Flow dynamics were compared between the groups. Doppler ultrasonographic data were analyzed median 12 (3‐47) months after LVAD implantation. CA‐PSV was lower in LVAD group compared with the other two groups (p), MCA‐PSV of LVAD and heart failure groups were similar and lower than healthy volunteers (p). The highest values for CA‐EDV were found in LVAD group (pp). For PI and RI, in all CA and MCA, LVAD group had lower indices compared with the other two groups (p). In addition, MCA flow analysis in patients with LVAD was identified for the first time with this study.

The predisposition to atrial fibrillation (AF) in mitral stenosis (MS) has been demonstrated with several electrocardiographic (increased P-wave dispersion) and echocardiographic parameters (atrial electromechanical delay). Despite the improvement in P-wave dispersion after percutaneous mitral balloon valvuloplasty (PMBV), the changes in echocardiographic parameters related to AF risk are unknown. In this study we aimed to investigate the acute effect of PMBV on atrial electromechanical delay (EMD) assessed by tissue Doppler echocardiography in addition to electrocardiographic parameters. This single-center study consisted of 30 patients with moderate or severe MS (23 females and seven males, aged 36.5 ± 8.5 years, with a mean MVA of 1.1 ± 0.2 cm²) who underwent successful PMBV without complication at our clinic and 20 healthy volunteers from hospital staff as a control group (16 females and four males, aged 35.4 ± 6 years). We compared the two groups in regard to clinical, electrocardiographic and echocardiographic features. The patients with MS were also evaluated after PMBV within 72 h of the procedure. The P-wave dispersion was calculated from12-lead ECG. Interatrial and intra-atrial EMDs were measured by tissue Doppler echocardiography. These ECG and echocardiographic parameters after PMBV were compared with previous values. The maximum P-wave duration (138 ± 15 vs. 101 ± 6 ms, p < 0.01), PWD (58 ± 18 vs 23 ± 4, p < 0.01), the interatrial (55 ± 16 vs 36 ± 11 ms, p < 0.01) and left-sided intra-atrial EMD (40 ± 11 vs 24 ± 12 ms, p < 0.01) were higher in patients with MS than in healthy subjects. The left atrial (LA) diameter, LA volume and LA volume index had positive association with the interatrial (r = 0.5, p < 0.01; r = 0.5, p < 0.01 and r = 0.5, p < 0.01, respectively) and left-sided intra-atrial EMD (r = 0.5, p < 0.01; r = 0.4, p < 0.01; r = 0.4, p < 0.01 respectively). After PMBV, the interatrial (55 ± 16 vs. 40 ± 11 ms, p < 0.01) and left-sided intra-atrial EMD (40 ± 11 vs 31 ± 10, p < 0.01) showed significant improvement compared to previous values. There was also a statistically significant difference in maximum P-wave duration and PWD between pre-and post-PMBV (138 ± 15 vs 130 ± 14, p < 0.01, and 58 ± 18 vs 49 ± 16, p < 0.01, respectively). Our study shows that PMBV has a favorable effect on the electrocardiographic and echocardiographic parameters related with AF risk in patients with MS. Die Prädisposition zum Vorhofflimmern (VF) bei Mitralstenose (MS) ist an verschiedenen elektrokardiographischen (vermehrte P-Wellen-Dispersion) und echokardiographischen Parametern [atriale elektromechanische Verzögerung („electromechanical delay“, EMD)] nachgewiesen worden. Trotz der Besserung der P-Wellen-Dispersion (PWD) nach perkutaner Mitralklappen-Ballondilatation („percutaneous mitral balloon valvuloplasty“, PMBV) sind die Veränderungen echokardiographischer Parameter, die in Bezug zum VF-Risiko stehen, nicht bekannt. In der vorliegenden Studie war es Ziel, die akute Wirkung der PMBV auf die atriale EMD zu untersuchen, welche durch Gewebedopplerechokardiographie und elektrokardiographische Parameter bestimmt wurde. An der Einzelzenterstudie nahmen 30 Patienten mit mittelgradiger oder schwerer MS teil [23 Frauen, 7 Männer, Alter: 36,5±8,5 Jahre, mittlere Mitralklappenöffnungsfläche („mitral valve area“, MVA): 1,1±0,2 cm²], bei denen eine PMBV erfolgreich komplikationslos in unserer Klinik durchgeführt wurde, sowie 20 gesunde Probanden des Krankenhauspersonals als Kontrollgruppe (16 Frauen, 4 Männer, Alter: 35,4±6 Jahre). Wir verglichen die beiden Gruppen im Hinblick auf klinische, elektrokardiographische und echokardiographische Merkmale. Innerhalb von 72 h nach der PMBV wurden die Patienten mit MS nachuntersucht. Die PWD wurde anhand des 12-Kanal-EKG berechnet. Gewebedopplerchokardiographisch erfolgte die Messung der interatrialen und intraatrialen EMD. Diese EKG- und echokardiographischen Parameter nach PMBV wurden mit den vorherigen Werten verglichen. Maximale P-Wellen-Dauer (138 ± 15 vs. 101 ± 6 ms, p < 0,01), PWD (58 ± 18 vs. 23 ± 4, p < 0,01), interatriale (55 ± 16 vs. 36 ± 11 ms, p < 0,01) und linksseitige intraatriale EMD (40 ± 11 vs. 24 ± 12 ms, p < 0,01) waren bei den Patienten mit MS höher als bei den Gesunden. Der linksatriale (LA-)Durchmesser, das LA-Volumen und der LA-Volumenindex waren positiv mit der interatrialen (r = 0,5, p < 0,01; r = 0,5, p < 0,01 bzw. r = 0,5, p < 0,01) und linksseitigen intraatrialen EMD (r = 0,5, p < 0,01; r = 0,4, p < 0,01 bzw. r = 0,4, p < 0,01) assoziiert. Nach PMBV wiesen interatriale (55 ± 16 vs. 40 ± 11 ms, p < 0,01) und linksseitige intraartriale EMD (40 ± 11 vs. 31 ± 10, p < 0,01) eine signifikante Verbesserung im Vergleich zu vorher auf. Außerdem war der Unterschied bei maximaler P-Wellen-Dauer und PWD vor und nach PMBV statistisch signifikant (138 ± 15 vs. 130 ± 14, p < 0,01 bzw. 58 ± 18 vs. 49 ± 16, p < 0,01). Die vorliegende Studie zeigt, dass eine PMBV sich günstig auf EKG- und echokardiographische Parameter auswirkt, die in Bezug zum VF-Risiko bei Patienten mit MS stehen.

Water intoxication, defined as excessive water ingestion within a short period of time, may cause severe neurologic and cardiac symptoms. This condition is commonly seen in psychiatric patients, however the ingestion of excessive water is an infrequent method for attempting suicide. In this case report we present a 51-year-old woman with ventricular fibrillation due to electrolyte imbalance caused by excessive water ingestion during a suicide attempt. The patient was admitted to our emergency clinic with altered consciousness and agitation. She was hypertensive and neurological examination revealed no lateralizing signs. Ventricular arrhythmias, cardiopulmonary arrest and tonic-clonic seizure were observed during hospitalization. Blood chemistry showed hyponatremia and hypokalemia relevant to the patient’s history of ingestion of 12 liters of water in 4 hours time. After electrolyte disturbances were corrected, ventricular arrhythmias and seizure did not recur. The patient was referred for psychiatric evaluation and was discharged with antidepressive medication. Although water intoxication is well described in psychiatric disorders such as schizophrenia, it has not been previously reported in depressive patients with suicidal thought. Awareness of the clinical presentation of this rare situation may prevent potentially fatal complications