A new surgical approach for aorta-right atrial tunnel with right coronary artery orifice.

Aorta-right atrial tunnel is a rarely seen congenital anomaly with an unknown etiopathology. Due to its life-threatening complications, it must be treated either surgically or by transcatheterization technique as soon as possible. Planning the treatment strategy considering the relation between the aorta-right atrial tunnel and coronary arteries is of utmost importance. Herein, we report a young case of a right coronary artery ostium originating from the proximal part of aorta-right atrial tunnel and her successful treatment with a new surgical technique using a pericardial patch.

Predictors of in-hospital mortality following redo cardiac surgery: Single center experience.

PURPOSE: Redo cardiac operations represent one of the main challenges in heart surgery. The purpose of the study was to analyze the predictors of in-hospital mortality in patients undergoing reoperative cardiac surgery by a single surgical team. METHODS: A total of 1367 patients underwent cardiac surgical procedures and prospectively entered into a computerized database. Patients were divided into 2 groups based on the reoperative cardiac surgery (n = 109) and control group (n = 1258). Uni- and multivariate logistic regression analysis were performed to evaluate the possible predictors of hospital mortality. RESULTS: Mean age was 56 ± 13, and 46% were female in redo group. In-hospital mortality was 4.6 vs. 2.2%, p = 0.11. EuroSCORE (6 vs. 3; p < 0.01), cardiopulmonary bypass time (90 vs. 71 min; p < 0.01), postoperative bleeding (450 vs. 350 ml; p < 0.01), postoperative atrial fibrillation (AF) (29 vs. 16%; p < 0.01), and inotropic support (58 vs. 31%; p = 0.001) were significantly different. These variables were entered into uni- and multivariate regression analysis. Postoperative AF (OR1.76, p = 0.007) and EuroSCORE (OR 1.42, p < 0.01) were significant risk factors predicting hospital mortality. CONCLUSIONS: Reoperative cardiac surgery can be performed under similar risks as primary operations. Postoperative AF and EuroSCORE are predictors of in-hospital mortality for redo cases.

Positive clinical outcomes of the saphenous vein interposition technique for ruptured popliteal artery aneurysm.

PURPOSE: Popliteal artery aneurysms (PAAs) can be treated successfully by surgical and endovascular methods; however, the best treatment strategy for a ruptured PAA has yet to be established. We assessed the clinical results of using saphenous vein interposition to treat ruptured PAAs in our hospital. METHODS: The subjects of this study were seven men (average age 59 years, range 43-71 years), who underwent emergency surgery for a ruptured PAA at our hospital between January 2007 and November 2012. The patients were assessed after 1, 6, and 12 months, postoperatively. RESULTS: All included patients underwent saphenous vein graft interposition via a medial approach. No complications or graft thromboses were encountered in the immediate postoperative period. The patients were discharged after an average of 4 days postoperatively (range 3-5 days). The patients were followed up for an average of 32 months (range 2-60 months). The medium-term graft patency was 100%. No patients suffered early or medium-term limb loss and there was no mortality. CONCLUSION: Based on our positive results, saphenous vein graft interposition should be considered as the first choice of surgical treatment for a ruptured PAA.

Evaluation of coronary artery-saphenous vein composite grafts: the aortic no-touch technique.

We retrospectively compared the results of conventional coronary artery bypass grafting (CABG) performed on patients who showed no preoperative evidence of serious atherosclerosis of the ascending aorta with the results of the aortic no-touch technique (using coronary artery-saphenous vein composite grafts) on CABG patients who did show such evidence. From 2003 through 2012, 3,152 consecutive patients underwent isolated primary CABG at our hospital. We chose 360 for the current study. The study group (n=120) comprised patients who had undergone operation via the aortic no-touch technique. Propensity-score-matching (1:2) was used to select the control group of 240 patients who had undergone conventional CABG. Early and late survival rates, reintervention-free survival rates, and freedom from cardiac death were compared. Early and late mortality rates were similar in the study and control groups (P=0.19 vs P=0.29, respectively), as were cardiac-related death (2.5% vs 2.1%, respectively; P=0.53) and overall death (8.3% vs 7.9%, respectively; P=0.51). Overall survival rates were 91.7% vs 92.1% and freedom-from-cardiac-death rates were 97.4% vs 97.5% (P=0.71 vs P=0.78, respectively; mean follow-up period, 5.27 ± 2.51 yr). Reintervention-free survival rates were also similar (96.7% vs 98.8%, respectively; P=0.2). As a result of the similar rates of early and late survival, reintervention-free survival, and freedom from cardiac death, we conclude that the aortic no-touch technique with composite grafts might be a reasonable option in patients who have atherosclerotic ascending aorta that cannot be clamped.

Large pseudoaneurysm of the sinus of Valsalva after surgery for aortic valve endocarditis.

Patients who undergo prosthetic aortic valve replacement for infective endocarditis and have no recurrent infection after surgery, rarely develop pseudoaneurysm of either the aortic root or the sinus of Valsalva (SV). Pseudoaneurysm of the SV can have fatal complications, including rupture. The case is reported of a large pseudoaneurysm of the SV that developed after surgical intervention for aortic valve endocarditis, and which was successfully treated.

Pre- and perioperative risk factors predicting neurologic outcomes after coronary artery bypass surgery in patients with pre-existing neurologic events.

BACKGROUND: A neurologic event (NE) after coronary artery bypass graft (CABG) surgery is a principal complication affecting morbidity and mortality. We investigated the risk factors predicting postoperative NEs and survival in patients with pre-existing NE undergoing CABG. METHODS: Between 2001 and 2012, 3137 patients underwent isolated primary CABG. The data were stored in a computerized database and retrospectively evaluated. Patients were divided into 2 groups based on the existence of preoperative NE (study group; n=126) and without NE (n=3011). Uni- and multivariate logistic regression analyses were performed to evaluate the possible predictors of postoperative NEs. Survival was determined using Kaplan-Meier survival analyses of the study group and propensity score-matched control group. RESULTS: The mean age of the 3137 patients was 60±9 years, and 28% (n=885) were female. Postoperative NE was seen in 4 (3.2%) patients with pre-existing NE and in 16 (0.5%) without pre-existing NE. Preoperative NE (odds ratio 4.47; 95% confidence interval 1.32-15.18; P=.01) and age (≥70 years; odds ratio 2.98; 95% confidence interval 1.21-7.33; P=.01) showed strong multivariate associations with postoperative NE. Median CHA2DS2-VASc scores were 4.5 (interquartile range 3-5) and 3 (range 0-4) in patients in the pre-existing and without NE groups, respectively (P=.01). The overall mean follow-up was 4.6±3 years. Overall survival rates (88.1% and 94%, respectively) were different between the 2 groups (P=.02). CONCLUSIONS: Preoperative neurologic events and advanced age are significant risk factors predicting postoperative neurologic events. Meticulous management of the ascending aorta and carotid artery are important in diminishing postoperative neurologic events. A pre-existing neurologic event is also predictive for decreased overall survival.

Hemodynamic effects of left upper extremity arteriovenous fistula on ipsilateral internal mammary coronary artery bypass graft.

OBJECTIVE: Arteriovenous fistula (AVF) in patients undergoing hemodialysis (HD) may cause coronary left internal mammary artery (IMA) steal. This phenomenon was demonstrated by few prospective studies with limited number of patients and case reports. We aimed to demonstrate with a relatively larger patient population that the AVF may cause ipsilateral IMA steal. METHODS: We included 22 prospective patients undergoing HD who had left IMA to left anterior descending artery graft and left upper limb AVF. Right IMA was taken as control. Flows were assessed by using color Doppler ultrasonography. RESULTS: The mean age was 57.8 ± 9 years. Statistically nonsignificant increases in AVF flow and decreases in left IMA flow were observed during HD compared with pre-HD. Moreover, fistula localization did not affect median left IMA flows (for peak systolic velocity [PSV] 43.7 versus 70 cm/s, respectively; p = 0.7, and for end diastolic velocity [EDV] 3.4 versus 6.5 cm/s, respectively; p = 0.7). We have not detected significant difference in left IMA flows during HD (median values of PSV 58.4 versus 68.4 cm/s, respectively; p = 0.1, and EDV 6.4 versus 4.4 cm/s, respectively; p = 0.08). Only three patients experienced dialysis-induced reduction of ipsilateral IMA flow that was accompanied by evidence of hypokinesia of the anterior left ventricular wall without clinical angina. CONCLUSIONS: Hemodynamically affected left IMA flow by ipsilateral upper extremity AVF may cause steal phenomenon. Hemodynamic differences between left and right IMAs in patients undergoing HD via left wrist and brachial fistulae are limited.

Endovascular treatment and the long-term results of postpartum deep vein thrombosis in 18 patients.

PURPOSE: We aimed to describe the long-term outcome of endovascular treatment of iliofemoral deep vein thrombosis in the postpartum period. MATERIALS AND METHODS: Between 2002 and 2010, 18 consecutive female patients with acute or subacute iliofemoral deep vein thrombosis in the postpartum period who had endovascular treatment were retrospectively evaluated. Treatment consisted of manual aspiration thrombectomy with or without catheter-directed thrombolysis. Stents were placed in the iliac veins, if deemed necessary. Clot removal was graded as complete (>95%), partial (50%-95%), and poor (<50%). RESULTS: The initial treatment was technically successful in 17 patients (94%). There was complete clot removal in 15 of 22 limbs (68%). Twenty-three stents were implanted in 15 patients (83%). The primary and secondary patencies were 58% and 82% at one year, 58% and 72% at three years, and 58% and 58% at five years, respectively. There were recurrent thromboses in 11 patients (61%), which occurred within the first month in nine of these patients (81%). Ten patients had repeated intervention, and five had successful outcomes. At a mean follow-up of 30 months, 11 patients had uninterrupted in-line flow in the affected lim b, and six patients did not. Six of the patients with uninterrupted flow were asymptomatic, and five patients had minimal swelling at the ankle. CONCLUSION: Endovascular treatment of postpartum iliofemoral deep vein thrombosis with percutaneous aspiration thrombectomy alone or combined with catheter-directed thrombolysis and iliac vein stenting is an effective therapy resulting in a high rate of thrombus removal. However, recurrences are high, particularly in the first post-intervention month. Frequent patient followup in the first post-intervention month is necessary.

Endovascular treatment of acute and subacute iliofemoral deep venous thrombosis by using manual aspiration thrombectomy: long-term results of 139 patients in a single center.

PURPOSE: To evaluate the immediate and long-term outcomes of percutaneous manual aspiration thrombectomy with provisional stent placement in treating acute and subacute iliofemoral deep venous thrombosis (DVT). MATERIALS AND METHODS: One hundred and thirty-nine consecutive patients (75 women; mean age, 51 years) with acute (n=110) or subacute (n=29) iliofemoral DVT underwent endovascular treatment (total of 148 limbs). All patients were treated with percutaneous manual aspiration thrombectomy by using large-bore guiding catheters with adjunctive catheter-directed thrombolysis and stent placement, if needed. Venography was used to grade thrombus removal. RESULTS: Thrombus removal was less than 50% in five limbs (3.4%), between 50% and 95% in 45 limbs (30.4%), and more than 95% in 98 limbs (66.2%). At least one stent was placed in 99 limbs. Recurrent thrombosis occurred in 27 patients, mostly during the first few months after the procedure. Rethromboses were more frequent among postpartum patients. One patient had a major pulmonary embolism. No major hemorrhage or procedure-related deaths occurred. CONCLUSION: Manual aspiration thrombectomy is a safe, rapid, and effective treatment option for acute and subacute iliofemoral DVT. Hence, catheter-directed thrombolysis may not be required in a majority of patients.

Ultrasound-guided puncture of the femoral artery for total percutaneous aortic aneurysm repair.

PURPOSE: The purpose of this study was to evaluate the outcomes of ultrasound-guided femoral artery access for total percutaneous endovascular repair of abdominal and thoracic aortic aneurysms. MATERIALS AND METHODS: Total percutaneous aneurysm repair of the abdominal and thoracic aorta was performed in 52 consecutive patients (46 males, 6 females; mean age, 64.6±16 years; age range, 24-93 years) in a total of 85 access arteries. Of the aortic aneurysms repaired, 33 were abdominal, and 19 were thoracic. Ultrasound- guided puncture of the access artery was performed in all patients. The access artery was closed with a Prostar XL device at the end of the procedure. RESULTS: The outer diameter of the vascular sheaths or the stent graft system ranged from 14 F to 27 F. All but one patient achieved successful closure of the arterial puncture with the closure device. One patient required surgical cutdown because of device failure. Two patients required long-duration manual compression. Technical success was achieved in 49 patients (94%). Forty-five patients (87%) were discharged on the first postoperative day. There were no complications of the access arteries one day or one month postoperatively, as determined by ultrasonography and computed tomography examinations, respectively. The mean diameters of the access arteries prior to and one month after the procedure were unchanged, as demonstrated by computed tomography. CONCLUSION: Ultrasound-guided puncture of the common femoral artery for percutaneous closure of the access site has a high technical success rate and a very low complication rate. The addition of ultrasound guidance decreases the difficulty of the procedure and helps to avoid some of its complications.

Papillary fibroelastoma of the right coronary cusp.

Cardiac papillary fibroelastoma (CPF) is a pathologically benign cardiac tumor. This tumor usually arises from cardiac valves, and it is the most common cardiac valvular tumor. This usually single and pedunculated tumor should be surgically treated when the mass is mobile and the patient has experienced a prior stroke, even if the stroke has manifested as a transient ischemic attack. Surgical treatment is definitive, and no recurrences have been reported in the literature. We describe a patient who had a diagnosis of CPF while undergoing investigation for a cryptogenic stroke.

Percutaneous aspiration thrombectomy in the treatment of lower extremity thromboembolic occlusions.

PURPOSE: To report the immediate and midterm results of manual aspiration thrombectomy as the first thrombus removal method in the treatment of acute or early chronic arterial thromboembolism in the lower extremity. MATERIALS AND METHODS: Retrospective review of 40 limbs in 37 nonconsecutive patients between March 2006 and March 2008 (21 female [57%], 16 male; mean age, 67 +/- 10 years; age range, 42-84 years) who had percutaneous aspiration thrombectomy for lower limb arterial thromboembolism. Twenty-nine legs had acute ( < 14 days) and 11 legs had early chronic (15-60 days) thromboembolism. Clinical categories of limb ischemia were stage I in 12 limbs, stage IIa in 17 limbs, and stage IIb in 11 limbs. RESULTS: Technical success was achieved in 35 limbs (88%). Complete thrombus removal was achieved in 26 of 29 limbs (90%) with acute occlusions and 4 of 11 limbs (36%) with early chronic occlusions (P < 0.05, chi(2) test). Amputation-free survival rate was 100% at one month, 93% at one year, and 93% at two years with Kaplan-Meier survival analysis. Freedom from symptoms of claudication or critical limb ischemia was achieved in 31 of 39 limbs (80%) at one month and 25 of 35 limbs (71%) at one year. There were three major complications and ten minor complications. CONCLUSION: Percutaneous aspiration thrombectomy is a rapid and effective way of removing thrombus in thromboembolic occlusions of the limb arteries below the inguinal ligament. It can be used in patients with acute limb ischemia (Rutherford clinical category IIb).

A prospective randomized double-blind study to determine the effect of thoracic epidural neostigmine on postoperative ileus after abdominal aortic surgery.

BACKGROUND: Postoperative ileus is a major gastrointestinal complication of abdominal aortic surgery leading to increased rates of morbidity and mortality, longer lengths of hospital stay, and higher costs. In this study, we evaluated the effect of epidurally administered neostigmine on postoperative ileus after abdominal aortic surgery. METHODS: We enrolled 45 patients who were scheduled for elective abdominal aortic surgery at our institution. All patients received identical general and epidural anesthesia. Before the induction of general anesthesia, an epidural catheter was placed at the T7-T8 intervertebral space, and 20 mL bupivacaine (0.5%) was injected over 15 min. Patients were randomized into two groups. Patients received a 5 mL bolus of neostigmine (1 microg/kg) diluted with normal saline (Group 1) or a 5 mL bolus of normal saline (Group 2) via an epidural catheter at the end of surgery and 8 h postoperatively. Times of bowel sounds were recorded postoperatively in the intensive care unit. Times of daily passage of flatus and defecation also were recorded. RESULTS: Times to the first bowel sounds and the first flatus were significantly shorter in Group 1 than they were in Group 2 (11.6 +/- 11.2 h vs 22.6 +/- 12.8 h and 21.8 +/- 15.6 h vs 36.6 +/- 19.1 h, respectively, P < 0.05). The times to first defecation were similar in both groups (P > 0.05). Nausea was more frequent in patients in Group 2 than in Group 1 (P < 0.05). The incidence of postoperative complications was similar between the groups (P > 0.05). CONCLUSIONS: Thoracic epidural neostigmine enables faster restoration of bowel sounds and shortens duration of postoperative ileus after abdominal aortic surgery.

Iliac vein compression syndrome: outcome of endovascular treatment with long-term follow-up.

OBJECTIVE: To retrospectively evaluate technical success and long-term outcome of endovascular treatment in patients with iliofemoral deep vein thrombosis (DVT) due to iliac vein compression syndrome (IVCS). MATERIALS AND METHODS: Between March 2003 and September 2006, 36 consecutive patients (26 women [72%], 10 men, mean age 50+/-18 years) with acute or chronic iliofemoral deep vein thrombosis due to iliac vein compression syndrome were evaluated for outcome of endovascular treatment. Stent patency was estimated by using the Kaplan-Meier method. RESULTS: Technical success was achieved in 34 of 36 patients (94%). Six patients with acute or subacute thrombosis had chronic occlusion of the left common iliac vein. Rethrombosis of the stents was observed in four patients. Primary and secondary patency rates were 85 and 94% at 1 year, and 80 and 82% at 4 years. Resolution of symptoms was achieved in 17 of 20 patients (85%) with acute and subacute DVT, and 4 of 16 patients (25%) with chronic DVT. Major complication was seen in one patient (3%). CONCLUSION: Intimal changes in the left common iliac vein are mostly chronic in nature even in patients with acute DVT secondary to IVCS. Endovascular treatment with stent placement has a high technical success rate and good long-term patency in the treatment of acute and chronic DVT due to IVCS. Symptomatic improvement seems to be better in patients with acute than chronic DVT due to IVCS.

Intima-media thickness in patients with rheumatic mitral stenosis.

The aim of the study was to determine carotid artery intima-media thickness (IMT) in patients with rheumatic mitral stenosis (RMS). Between January 2001 and December 2003, 112 consecutive patients who had been diagnosed with RMS were screened. Patients with known cerebrovascular disease, coronary artery disease, diabetes, hypertension, left ventricular hypertrophy, hyperlipidemia, abnormal laboratory results, smoking, or age over 50 years were excluded. Forty-eight patients (43 women, 5 men, mean age 39.7 +/-8.3 years) with RMS without risk factors were enrolled in the study. Age- and sex-matched healthy individuals (n = 48; 43 women, 5 men, mean age 39.6 +/-8.6 years) with normal echocardiographic findings constituted the control group. Carotid IMT was determined by using a high-resolution ultrasound system equipped with a 7-MHz imaging probe (Acuson 128 XP CI) with a computer measurement software. The mean common carotid artery IMT thicknesses both in the right (0.604 +/-0.112 mm vs 0.521 +/-0.072 mm) and in the left side (0.581 +/-0.097 mm vs 0.516 +/-0.065 mm) were significantly higher in patients with RMS than in the control group (p < 0.001). Backward stepwise logistic regression analysis identified RMS as independent predictors of increased IMT (OR, 17.25 (CI, 3.99 to 76.28), p <0.001). The present study demonstrated that RMS is associated with increased IMT. The findings indicate that in patients with RMS not only valvular but also systemic endothelium is damaged.

Value of preoperative echocardiography in the prediction of postoperative atrial fibrillation following isolated coronary artery bypass grafting.

The value of echocardiography, especially tissue Doppler imaging (TDI), in the assessment of risk of postoperative atrial fibrillation (AF) after coronary artery bypass grafting (CABG) is not clear. One hundred two consecutive patients (80 men; mean age 61 +/- 10 years) who underwent elective isolated CABG were included in the study. All patients underwent conventional transthoracic echocardiography and TDI of the left and right heart before surgery. Also, 24-hour Holter recordings were obtained for all patients. The study end point was the development of postoperative AF. The surgical mortality rate was 2%. Postoperative AF occurred in 18 patients (18%). Patients with postoperative AF have been significantly older than patients without postoperative AF (73 +/- 7 vs 58 +/- 9 years, respectively; p <0.001). Compared with patients without postoperative AF, a significantly higher proportion of patients with postoperative AF experienced paroxysmal AF before surgery (6% vs 33%, respectively; p = 0.001). Patients with postoperative AF had a significantly larger mean left atrial diameter compared with patients without postoperative AF (37 +/- 3 vs 35 +/- 3 mm, respectively; p = 0.012). Multivariate logistic regression analysis identified age as the most significant predictor of postoperative AF (odds ratio 1.254, 95% confidence interval 1.127 to 1.396; p <0.001). Of the echocardiographic variables, only left atrial diameter was identified as a significant predictor of postoperative AF (odds ratio 1.250, 95% confidence interval 1.055 to 1.562; p = 0.047). In conclusion, in the prediction of postoperative AF after isolated CABG, preoperative transthoracic echocardiography, including both conventional echocardiography and TDI, is of little value.

Wake-up test after carotid endarterectomy for combined carotid-coronary artery surgery: a case series.

OBJECTIVE: In combined carotid-coronary artery surgery, it is important to determine patients' neurologic status after carotid endarterectomy (CEA). An initial stroke could be exacerbated by cardiopulmonary bypass required for coronary artery bypass graft (CABG) surgery. Various monitoring methods (eg, electroencephalogram) have been used to reduce neurologic deficits during CEA under general anesthesia. However, none of the methods of determining neurologic status of patients are ideal during the time between the end of CEA and the beginning of CABG surgery. In this study, patient's neurologic status was assessed after CEA with a wake-up test to identify stroke before CABG surgery. DESIGN: A prospective nonrandomized case series. SETTING: Single institution, university hospital. PARTICIPANTS: Forty-four patients with carotid artery stenosis and coronary artery disease underwent combined carotid-coronary artery surgery. INTERVENTIONS: After CEA, propofol and remifentanil anesthesia was discontinued, the wake-up test was performed, and then anesthesia was reinstituted for CABG surgery. MEASUREMENTS AND RESULTS: A total of 48 wake-up tests were performed in 43 patients. Two wake-up tests were performed in each of the 5 patients who underwent bilateral CEA. Postoperative stroke were seen in 2 patients. In the first patient, despite a normal wake-up test, the stroke occurred in the cerebral hemisphere contralateral to the CEA, and the patient recovered within 12 days. In the second patient, there was a positive wake-up test after CEA, and he recovered within 3 days. One patient died postoperatively because of ventricular failure. CONCLUSIONS: Although this is a case series, the authors believe that performing a neurologic examination using a wake-up test may make a contribution and increases the safety of combined surgical procedures in patients with coronary and carotid artery disease.