Sabit Sarikaya

Background: Acute kidney injury (AKI) is a frequent and serious complication after the implantation of continuous-flow left ventricular assist devices (CF-LVADs), often mediated by right ventricular (RV) dysfunction, systemic venous congestion, and subsequent suboptimal device filling. The pulmonary artery pulsatility index (PAPi) is a hemodynamic parameter reflecting RV function. This study evaluated the predictive value of preoperative PAPi for postoperative AKI in ambulatory advanced heart failure patients. Methods: A total of 121 stable, ambulatory advanced heart failure patients (INTERMACS profiles 4–6) who underwent CF-LVAD implantation between 2020 and 2024 were retrospectively analyzed. Preoperative demographic, clinical, and invasive hemodynamic parameters were collected. Postoperative AKI was defined using serum creatinine criteria according to the RIFLE consensus during the first two postoperative days. Results: Postoperative AKI developed in 43 patients (35.5%). The mean PAPi value was significantly lower in the AKI group compared with the non-AKI group (1.4 ± 0.4 vs. 3.2 ± 1.2, p = 0.001). Preoperative right atrial pressure (RAP) was significantly higher in patients who developed AKI. Receiver operating characteristic (ROC) curve analysis demonstrated modest discrimination, with an area under the curve (AUC) of 0.62 (95% CI: 0.52–0.73). A PAPi cut-off value of 2.1 yielded a sensitivity of 0.82 and a specificity of 0.42. Conclusions: In ambulatory advanced heart failure patients undergoing CF-LVAD implantation, a preoperative PAPi value below 2.1 shows an association with a higher risk of postoperative AKI. However, given its modest independent discriminative capacity (AUC 0.62) and potential dependence on venous congestion metrics like RAP, these preliminary findings should be considered exploratory and hypothesis-generating, warranting further external validation in broader cohorts.

Nutcracker syndrome (NCS) is a rare vascular compression disorder characterized by the extrinsic compression of the left renal vein (LRV), most commonly between the abdominal aorta and the superior mesenteric artery. Although increasingly recognized in recent years, NCS remains a controversial clinical entity due to the absence of universally accepted diagnostic criteria and standardized management algorithms. The syndrome presents with a broad clinical spectrum, ranging from asymptomatic hematuria to debilitating flank pain and pelvic congestion symptoms. Advances in diagnostic imaging and minimally invasive interventions have significantly expanded available treatment options; however, the optimal therapeutic strategy remains unclear. This chapter provides a comprehensive overview of the anatomy, pathophysiology, clinical manifestations, diagnostic evaluation, and contemporary management strategies of NCS. Current evidence regarding conservative treatment, surgical reconstruction, endovascular interventions, and emerging extravascular techniques is critically reviewed. Comparative outcomes, procedural limitations, and future directions are also discussed to provide a practical and evidence-based perspective for clinicians involved in the management of this complex condition.

Objective: The modified David V technique is one of the valve-sparing aortic root replacement (V-SARR) techniques, which is an alternative to traditional composite valve graft root replacement techniques. We aimed to analyse our longterm experience with the modified David V re-implantation technique for the treatment of aortic root aneurysm and significant aortic valve insufficiency. Methods: From March 2009 to November 2021 the modified David V re-implantation technique, one of the V-SARR techniques, was performed on 48 patients in our centre. The results were analysed retrospectively. Two different-sized grafts were used in all patients. The grafts used in the proximal position were larger than the distal grafts. We performed both intra-operative and post-procedural transoesophageal echocardiography on each patient. All patients were followed by means of transthoracic echocardiography. The mean follow-up period was 5.7 +/- 3.1 years.Results: The mean age of this cohort was 56.3 +/- 14.3 years (24-79) and the majority were men (75%). The mean aortic root diameter was 5.1 +/- 0.6 cm. The mean diameter for the assending aorta was 5.4 +/- 2.1 cm. The in-hospital mortality rate was 4.2% (n = 2). One patient needed aortic valve replacement in the early postoperative period. Two (4.2%) patients died in the early postoperative period and four (8.3%) died in the late postoperative period. Overall survival was 91 +/- 4 and 86 +/- 5% at one and five years, respectively. Aortic valve insufficiancy was at moderate levels postoperatively. Freedom from moderate to severe residual aortic insufficiency was 89.6% at 10 years. None of the patients needed late re-operation of the aortic valve postoperatively. Freedom from valve re-operation was 100% at the end of the follow up.Conclusions: Our study shows that the David V technique is associated with excellent long-term durability, a remarkably low rate of valve-related complications, and it protects the re-implanted native aortic valve from a second operation. Additionally this technique could be safely implemented in patients with a bicuspid aortic valve and acute type A aortic dissection without leaflet deformity.

Objective: This study aimed to share our experiences and outcomes with left renal vein (LRV) transposition and endovascular stenting in treating Nutcracker syndrome. Methods: Data of 20 female Nutcracker syndrome patients (mean age: 24 years) who underwent LRV transposition (n=15) or stenting (n=5) between July 2019 and June 2024 were retrospectively reviewed. Primary endpoints were morbidity and mortality. Secondary endpoints included late complications, patency, freedom from reintervention, and resolution of symptoms. Results: There were no major complications or mortality after either procedure. The most common signs and symptoms associated with LRV entrapment were left flank pain (100%, n=20), proteinuria (88%, n=15), and hematuria (47%, n=9). After both procedures, classical symptoms resolved in 89.5% (n=17) of patients for left flank pain, 57.8% (n=11) for proteinuria, and 82.3% (n=15) for hematuria. Four patients required reintervention [three after LRV transposition (two for occlusion and one for stenosis) and one after stenting (occlusion)]. The one-year primary patency rate was 87%, and the primary assisted patency rate was 100%. One-year primary patency rates were 91% for the transposition group and 75% for the stent group. The one-year freedom from reintervention was 83%. Conclusion: Both procedures can be used as primary treatments and have their advantages. This study shows that both methods are safe and effective.

Background: In this study, we shared our experience with the minimal invasive extracorporeal circulation system for coronary artery bypass grafting patients. Methods: A total of 163 patients were included in the retrospective study, with 83 patients (63 males, 20 females; mean age: 61.9±8.9 years; range, 35 to 81 years) undergoing coronary artery bypass grafting with minimal invasive extracorporeal circulation and 80 patients (65 males, 15 females; mean age: 60.5±8.8 years; range, 43 to 82 years) undergoing coronary artery bypass grafting with conventional cardiopulmonary bypass between July 2021 and April 2023. Elective coronary bypass performed by same surgical team were included in the study. Mortality, major adverse cardiac and cerebrovascular event, hospital stays and transfusion requirements were evaluated. Results: There were no significant differences in sex distribution, age, comorbidities, and blood values between the two groups. Intraoperatively, the minimal invasive extracorporeal circulation group had a slightly higher number of distal anastomoses and comparable times for aortic cross-clamp and cardiopulmonary bypass. Postoperative outcomes such as tamponade, bleeding, atrial fibrillation, left ventricular ejection fraction improvement or reduction, and postoperative drainage were similar between the two groups. However, the minimal invasive extracorporeal circulation group had fewer transfusions of packed red blood cells and fresh frozen plasma and a shorter length of stay in the intensive care unit. Conclusion: The minimal invasive extracorporeal circulation system effectively preserves blood, works with lower activated clotting time values without additional complications in coronary artery bypass grafting, and could present a better option for patients with anemia or patients with a relatively high risk for high-dose heparinization.