Mission and Vision of Our Department
The Department of Cardiovascular Surgery of Kocaeli University provides high quality and comprehensive patient care and consultation services in the field of adult and pediatric cardiac and vascular surgery. Cardiovascular surgery and medicine is one of the most dynamicly evolving fields of medicine today. Our department aims to use the innovations and advances in technology in its field to provide healtcare to the population of the region.
To train cardiovascular surgeons who know Turkey's health problems and are equipped with knowledge, skills and attitudes that can overcome the problems related to cardiology, cardiovascular surgery, who can practice medicine in domestic or international cardiovascular surgery clinics, apply them in accordance with the ethical rules of their profession, who are researching and questioning, constantly renew and develop themselves, and who are accepted at international level.
Services Provided by Our Department
The Department of Cardiovascular Surgery has 19 inpatient clinic beds (3 single private rooms, 8 double rooms), 6 intensive care unit beds and 1 operating room.
Our patient spectrum generally includes coronary artery disease, heart valve disease, congenital heart disease, occlusive artery diseases of the abdominal aorta and extremities, arteriovenous fistulas for hemodialysis, thoracic aortic aneurysms, abdominal aortic aneurysms, peripheral aneurysms, carotid artery stenosis, deep vein thrombosis, venous insufficiency ( varicose veins ), patients with venous ulcers.
In our clinic, more than 250 adult open heart surgeries (mainly coronary artery bypass graft operations, aortic valve and/or mitral valve replacements, thoracic aortic surgery), more than 20 pediatric open heart surgeries (mainly ventricular septal defect closure, atrial septal defect closure, patent ductus arteriosus closure), more than 350 vascular interventions (abdominal aortic surgery, upper and lower extremity peripheral artery surgery, varicose veins surgery and endovenous ablation) are conducting annually. Coronary bypass surgery, which constitutes the main group, is performed on-pump or off-pump (on beating heart). Our hospital is a reference hospital not only in Kocaeli province but also in the surrounding provinces, and our department includes a wide range of cases for adult and pediatric heart surgery. Over 5000 patients are examined annually in the out-patient clinic of our department.
Function of the Heart
Basically, pumping the oxygenated blood to the cells through the arterial system Collecting the unoxygenated blood through the venous system and sending it through the lungs to be cleaned and oxygenated again.
What is a Coronary Artery?
Coronary arteries are the vessels that supply the heart muscle. The heart provides its energy and oxygen needs with the blood carried by the coronary arteries. Coronary vessels are fed from the main artery (AORTA) leaving the heart. There are two main coronary arteries in the heart. (right and left main coronary arteries). The left main coronary artery(LMCA) is more important as it supplies a larger portion of the heart. The anterior descending branch (LAD), which separates from the left main coronary artery, is a very important vessel that feeds the most vital parts of the heart. The circumflex and diagonal branches, which are also branches of the left main coronary arteru, are important vessels that feed the left lateral and posterior wall of the heart. The right coronary artery and its branches supply the blood flow to the right and posterior walls of the heart.
What is Coronary Artery Disease?
Coronary artery disease is one of the most common and most important health problems today. Coronary artery disease means that the main vessels that feed the heart muscle are narrowed or blocked for various reasons, so that the heart cannot get enough nutrition. If not intervened in the future, it can cause a heart attack. Those with coronary artery disease complain of pain that lasts for 2-3 minutes, especially in their chest and left or right arms after exertion.
Although the cause of the disease is not known exactly;
Hyperlipidemia(high cholesterol levels)
Alcohol consumption and stress can be the reason.
In the treatment; medical treatment or surgery (coronary artery bypass graft) is recommended in the future.
In the coronary bypass operation, the veins taken from the legs and the arteries taken from the inner chest wall are used most frequently. In special cases, gastric vessels, anterior abdominal vessels, radial (forearm) artery and arm veins can also be used. One end of these vessels is sutured below the blocked coronary and the other end is sewn to the main vessel (aorta) coming out of the heart. Thus, blood flow is provided to the areas fed by the clogged vessel.
Heart Valves and Diseases
There are 4 valves in our heart, 2 of them between the atrium and the ventricles, and 2 of them between the ventricles and the great vessels coming out of the heart. Due to their structure, these valves allow blood to flow in one direction. The “AORTIC VALVE” between the left ventricle and the aorta, and the “MITRAL VALVE’’between the left atrium and the left ventricle are the two most important valves of the heart.
For various reasons, calcification of the heart valves and the adhesion of the elements forming the valve to each other can cause valve stenosis, and its degenerative enlargement causes valve insufficiency. Since the blood cannot flow easily enough in strictures, various degrees of discomfort occur, because it will run backwards in insufficiency.
The most important cause of valve diseases is acute rheumatic fever in childhood or youth. This usually occurs as a result of the body's resistance to a microorganism called streptococcus that causes sore throat. Another important reason is that the heart valves may be infected together with coronary artery disease or due to coronary artery disease.
Treatment of valve diseases is surgery. If the damaged cover cannot be repaired, it is removed and replaced with an artificial cover. With the developing technology, valve prostheses have developed a lot. However, patients with mechanical valves have to use some medications for life.
- You will be well enough to return home within 6-8 days after your surgery.
- You have an average recovery period of 6-8 weeks. During your recovery period, there may be forgetfulness, insomnia and loss of appetite. These are temporary.
- Because of the suppression of the body's immune mechanisms after the surgery, care should be taken against infection. Visitors are not accepted in the first days. Short-term visits may be accepted later on. However, contact should be avoided during visits.
Sutures and Bath
Generally, your stitches will be removed after 10 days or at your first control after discharge. After all your stitches are removed, you can sit down and take a shower with warm water.
We do not recommend a strict diet for the first month. In the next period, choose a diet restricted from cholesterol and salt.
- Prefer liquid oil instead of solid oil.
- Prefer white meat and fish instead of red meat.
- Avoid pastries and sugar as much as possible.
- Avoid gaining weight.
- Make your first walks indoors and on flat ground. Gradually increase your walking distance. You can walk for 45 minutes, three days a week at the most. There is no harm in climbing the stairs. However, as you will get tired more quickly, take a rest and climb the stairs.
- It takes a period of 6-8 weeks for your breastbone, also called the sternum, which was dissected during the surgery, to heal. During this period, you should not lie on your side, should avoid sudden right-left turns that may move your breastbone, and movements that will put weight on one arm, 5 kg. Overweight should not be lifted.
Do not smoke, do not be in a smoking environment.
You can drink alcohol from one glass, 2 times a week.
If you can climb two flights of stairs without any problems, it is okay to have sexual intercourse. Female patients in childbearing period;
- Whether pregnancy is allowed or not,
- Timing and considerations if given,
- Consult your doctor about contraception methods.
- Socks are used to prevent swelling in your feet and to reduce swelling. Wear your socks before you get out of bed in the morning, you can take them off at night.
- Make sure your socks are the right size.
Do not forget to get your prescription from your doctor when you are discharged. Use the prescribed medications regularly. You should use your medications continuously unless your doctor interrupts them during the controls.
When should I come for a check-up visit?
If everything goes well, you should come for a check-up visit after a week. Except this;
- Movement at the wound site
- Discharge at the wound site
- If you have palpitations, consult your doctor without waiting.
It is a drug that prevents blood from clotting. It prevents the formation of clots and the growth of the formed clot. However, it does not dissolve the pre-existing clot. The dose is adjusted by your doctor according to the blood test called INR.
Things to Do While Using Coumadin
- Take Coumadin as your doctor has advised you.
- Try to keep your daily eating habits and activities the same for every day, avoid unfamiliar foods and drinks.
- Do not neglect to have your blood tests done when asked.
- Consult your doctor in case of illness, injury or unstoppable bleeding.
- When you go to the dentist or in any healthcare practice, let the healthcare professional performing the operation know that you are using Coumadin.
Not to Do’s
- Do not take extra tablets as compensation.
- Do not use Coumadin if you are pregnant or likely to become pregnant.
- Do not use any other medication other than your doctor's advice.
- Avoid alcohol consumption.
- If you missed the medication, take your daily dose as soon as you remember, then go back to your normal schedule.
- If you forget to take 1 day never take two doses, continue with your normal schedule.
- If you forget to use it for 2 days or longer, consult your doctor.
- People who use Coumadin should stay away from sports such as boxing and karate.
Side Effects of Coumadin
Bleeding may occur when the drug dose is excessive.
- If you suffer from headache and dizziness,
- If your bleeding does not stop by clotting in shaving cuts and similar injuries,
- Nosebleeds(epistaxis) occur and the bleeding does not stop,
- If you have bleeding gums while brushing your teeth,
- If you are vomiting blood,
- If black and purple spots occur on your skin for unknown reasons,
- If your urine color is red and dark brown,
- If your stool is black or red when you go to the toilet,
- If you are bleeding more than normal during the menstrual period,
- When you feel unexpected pain and swelling CONSULT YOUR DOCTOR IMMEDIATELY.
Peripheral Artery Disease
Peripheral Artery Disease is a disease that occurs as a result of complete or partial occlusion of the arteries that supply blood flow to the arms, legs and internal organs, due to arteriosclerosis or rare reasons.
Who are at risk?
- >50 years old,
- Those with high blood pressure,
- Those who are overweighted,
- Those with chronic kidney failure,
- Those with high LDL (bad cholesterol) and triglyceride levels,
- Those with low HDL (good cholesterol) levels are at risk.
What are the Symptoms of the disease?
- Leg pain with walking,
- Numbness in the legs,
- Coldness in legs and feet, feeling of coldness,
- Color change in the feet,
- The hair on the back of the feet begins to fall out,
- In advanced cases, the formation of open wounds on the foot can be considered.
Which Treatments Are Used?
- Changing the lifestyle and diet,
- Regular exercise,
- Stent insertion,
- It can be considered as a surgical intervention.
- The type of treatment is determined according to the patient's condition.
What Should Be Considered?
- You should pay attention to your diet. A healthy diet ensures that cholesterol and fat levels in the blood are within normal limits and blood pressure is kept under control.
- You should quit smoking, if you can't, you can get professional help.
- You should not apply heat directly to your arm or leg. You may cause burns due to loss of sensation.
- Do not sit with your legs crossed for a long time. (You will prevent blood flow by sitting in this way.)
- You should not use flip-flops.
- Cut your nails straight after showering.
- You should protect your feet and legs from the cold.
- You should avoid wearing tight-fitting clothes, socks and shoes that squeeze your feet.
- You should use the medicines given by your doctor regularly.
It is defined as extension 1.5 times the diameter of a normal vessel.
It leads to two major problems:
- Thinning and tearing of the vessel wall due to aneurysm and bleeding,
-Clot formation in the aneurysm area and associated obstruction.
Aneurysm most commonly affects the aorta, which is the largest vessel leaving the heart. After leaving the heart, this vessel travels in the thorax, reaches the abdomen, and divides into 2 brnches that carry blood to the legs. Aneurysm can be seen in any part of the aorta, mostly in the abdominal part. Rarely, it may develop in the part of the thoracic cavity.
Most of the aneurysm patients do not have any complaints or symptoms and they are detected incidentally during examination or by tests such as chest X-ray, Doppler, tomography taken for other diseases. Some patients may notice that there is a mass in their abdomen that swells with the heartbeat. Most of the patients present with rupture of the aneurysm. Computed tomography is the most commonly used diagnostic tool in diagnosis.
If the diameter of the aneurysm has not reached the dimensions considered risky, drug therapy is given and followed up at regular intervals. If there is a faster growth than expected in the follow-ups or if it has reached a risky size, surgical intervention is required. In the surgery, the area with the aneurysm is removed and an artificial vessel greft is placed in its place. In recent years, selected patients who are thought to be risky for surgery can also be treated by placing a stent in this region with interventional treatment.
Patients presenting with aneurysm rupture should be operated immediately. However, despite the surgery, the mortality rate in these patients is very high.
We can collect vein diseases under 3 headline:
1. Varicose (varicose veins),
2.Chronic venous insufficiency,
3.Deep vein thrombosis and thrombophlebitis
Varicose veins are defined as the enlargement, elongation and twisting of the leg veins. It is more common in female than male. The incidence of varicose veins increases with age. They are more common in superficial (just under the skin) veins than in deep (embedded within the muscles) veins. Varicose veins are usually noticeable on the calf and back of the thigh.
Varicose veins causes and risk factors
- Increased blood pressure in the veins (events that make it difficult for blood to return)
- Damage or insufficiency of the valve in the vein: Valves are responsible for ensuring blood flow, especially against the gravitational effect of oxygen-poor blood from the legs to the heart, and is especially important for the veins to maintain the blood flow in the right direction. In this way, the blood in the veins always flows in one direction (toward the heart). Normally, the valves close to prevent backflow of blood. Leaky or damaged valves cause blood to back up and pool in the legs, resulting in swelling and varicose veins. Damage to the valves may have been due to a blood clot, a congenital defect (congenital defect), or chronic venous insufficiency.
We can list the risk factors for the development of varicose veins as follows:
-Congenitally weak leg vein valves
-History of deep vein thrombosis
-Pregnancy, especially during the first and last 3 months
-Prolonged standing in a fixed position
Symptoms in varicose veins
-Dark blue, convoluted veins just below the skin surface
-A group of thin, purple-colored stripes (spider-veins) on the skin, resembling a spider's web
-Feeling of heaviness or pain in the legs, cramps
-Burning, throwing or itching around the varicose vein
-Swelling in the lower legs, especially around the ankles
If the affected leg has been involved in an accident (e.g. due to a fall or other accident), chronic venous insufficiency and its complication, a leg ulcer (stasis ulcer), may occur. Leg ulcers are more common on the inner side of the leg at the wrist level. It is an open wound, and is usually small, close to the skin, and quite painful due to the emerging nerve endings. If left untreated, it may eventually become completely incurable. Infection can be compounded and the event can go as far as gangrene and result in amputation (cutting) of the affected leg.
The most commonly used method today is Doppler ultrasound. With this method, invisible deep veins can be examined and valve insufficiency can also be evaluated.
The treatment modalities of varicose veins are affected by many factors. Some of these are the severity of the sypmtoms, the amount of pressure in the veins and whether there is inflammation. In the early stages, patients may be asked to elevate the affected leg whenever possible and wear supportive elastic stockings to relieve pain and swelling. However, these strategies do not make things go away completely.
Sclerotherapy (foam treatment) is recommended for small varicose veins. It is not used for large varicose veins.
Apart from these, there are treatment methods such as classical surgery and laser.
Surgery and foam therapy also tend to produce good results. However, patients with varicose veins should then make lifestyle changes to reduce the risk of recurrence.
Chronic Venous Insufficiency, Postphlebitic Syndrome
Chronic venous insufficiency (CVI) is the advanced stage of leg vein disease in which the leg veins become insufficient, resulting in pooling of blood in the feet and legs. It occurs when there is an obstruction in the leg veins or damage to the one-way valves in the veins. Under normal conditions, these valves allow blood to flow only backwards in the direction of the heart. Inadequate valves, on the other hand, cause the blood from the legs to the heart to escape back with the effect of gravity and pool at the bottom.
Causes of chronic venous insufficiency
-Blood clot (venous thrombosis), inflammation (phlebitis), or damaged valves in the veins that block the blood flow
-Leg injury or surgery
-Obesity, which causes increased pressure in the leg veins, causing damage to the valves
- Standing still for long periods of time
-Congenital genetic deficiencies
DWithout careful treatment, SVR can progress to leg ulcers, and leg ulcers accompanying SVR are usually localized on the inside of the ankle, although they may be external. They do not occur on the front of the foot and above the knee.
Symptoms of CVI
-Swelling of the legs or ankles (edema)
-Prolonged itching or pain in the legs, cramps
-Brown discoloration of the skin, especially around the ankles
-Inflammation of the skin (dermatitis)
-Painful sores on the ankles or higher (leg ulcers, stasis ulcers)
How do we diagnose chronic venous insufficiency?
In many cases, the presence of characteristic symptoms (e.g. foot swelling, skin discoloration and wound development, ulceration) easily makes the diagnosis of CVI. The following conditions may also aid diagnosis:
- The presence of vein disease in the patient and his/her family
- The presence and localization of ulcers associated with venous insufficiency may be sufficient to make the diagnosis without the need for any additional testing.
- Doppler ultrasound, which uses high-frequency sound waves to detect venous blood clots and incompetent veins, is the most commonly used method. -Venography is a diagnostic method that was used in the past and is now rarely preferred.
- Ankle-arm index (ABI): This test compares the blood pressure of the arteries with the blood pressure in the arm. It is used in the screening of peripheral arterial diseases that can be found with venous diseases. This information is important as it can change the recommended treatment.
Treatment options for CVI
- Elevating the legs
- Wearing compression socks
- Drug therapy and surgical treatment in selected patients.
Patients with CVI should always follow their doctor's recommendations (eg, leg elevation and bandaging). Otherwise, recurrent problems with leg ulcers can cause vein inflammation (phlebitis). For some patients, lifelong anticoagulant therapy may be recommended. Centers with multidisciplinary teams are generally more successful in planning the treatment of patients with venous ulcers that are difficult to treat. These teams often include vascular surgeons, plastic surgeons, and close coordination with physical therapy. Vascular surgeons work to correct the underlying venous pathology. Plastic surgeons undertake wound care and reconstruction, while physical therapy reduces swelling with massage techniques and sophisticated bandages and applications.
Deep Vein Thrombosis and Thrombophlebitis
Thrombophlebitis is the inflammation of the vein and the formation of a clot in it.
Types of thrombophlebitis
-Superficial vein thrombosis (SVT)
-Deep vein thrombosis (DVT).
SVT is the formation of an occlusive blood clot in veins located close to the skin surface. SVT is usually painful, but these clots rarely break and move through the bloodstream, so they are not serious.
DVT is the formation of an occlusive blood clot in deep veins embedded in the muscles, usually in the lower leg, but sometimes in the lower abdomen or groin area. Although DVT does not cause many complaints, it commonly causes permanent damage to the vein. In addition, in DVT, the risk of all or a part of the blood clot breaking off and entering the bloodstream and going to the organs (embolism) is high. (around 50%). A pulmonary embolism is the movement of the circulating clot to the lungs, and its consequences can be fatal. Rarely, if the clot reaches the heart and there is a hole between the right side of the heart and the left side of the heart, the embolism can then travel through the body through the aorta and travel to the brain, leading to a stroke.
In many cases, embolism is the first sign of DVT.
Causes and risk factors of thrombophlebitis
The majority of people diagnosed with a SVT or DVT have at least one risk factor for blood clot formation. In many cases, there are two or more risk factors. These risk factors include:
- Surgical interventions (especially orthopedics, neurosurgery and large vessel interventions)
- Trauma, injuries
- Prolonged inactivity (e.g. long bed rests, long hours in front of the computer)
- Congenital (congenital) hypercoagulation syndromes
- Presence of varicose veins
- Advanced age
- Oral contraceptives (birth control pills) and hormone replacement therapy (HRT)
- Recent stroke
- Infection of the blood vessel
- Bleeding disorders (hemophilia)
- Inflammatory bowel disease
- Some types of cancer
- Irritation of vascular access
- Type 2 diabetes mellitus
- Previous thrombophlebitis
Signs and symptoms of thrombophlebitis
Only half of patients with DVT have symptoms directly related to DVT:
-Swelling and tenderness in the legs (may or may not be in the affected area)
-Throbbing or burning sensation
-Pain during movement
In contrast, superficial vein thrombosis (SVT), although not as serious as DVT, often has the following signs and symptoms:
-Swelling and tenderness in the affected area
-Inflamed veins visible through the skin and sensitive to touch
-A throbbing or burning sensation just under the skin
The diagnosis of thrombosis begins with a complete medical history and physical examination. A number of tests are used to confirm the diagnosis. Ultrasound gives very important information in diagnosis. This test carries 95 percent accuracy.
Blood tests: These tests look for the presence of certain clot-dissolving agents that usually accompany thrombophlebitis. However, a blood test by itself does not make a diagnosis.
Treatment and prevention
Blood clots will usually dissolve during normal healing as the body's clot-dissolving mechanisms kick in, so treatments are usually aimed at reducing symptoms and preventing the clot from becoming an embolism.
Treatment of superficial vein thrombosis (SVT):
-Hot application, anti-inflammatory drugs, compression socks
Deep vein thrombosis (DVT) treatment:
Although there are often no complaints in DVT, there is a risk that the blood clot may break off and cause a pulmonary embolism.
To prevent this, blood thinners and anticoagulants are given. Treatment is usually up to 6 months, but sometimes even longer at the doctor's request.
Anti-inflammatory drugs, antibiotics, compression stockings are other treatment methods that can be used.
• Professor.Dr. Şadan YAVUZ (Head of the Department)