Redo valve surgery with on-pump beating heart technique.

AIM: Reoperations have become of increasing frequency in the last four decades. Redo surgery is more complex than primary surgery and is associated with higher mortality and morbidity. We present our immediate and mid-term results of mitral and aortic prosthetic valve replacement undertaken with beating heart technique. METHODS: The prospective study included 26 consecutive redo valve surgery patients who underwent valve re-replacement. The operation was carried out on a beating heart using normothermic bypass without cross-clamping the aorta for mitral valve surgery and retrograde coronary sinus normothermic noncardioplegic blood perfusion during cross-clamping the aorta for aortic valve procedures. RESULTS: Twenty-six patients (mean age 50+/-15 years) underwent reoperation with beating heart technique. Twenty (76.9%) mitral prosthetic replacements, 4 (15.4%) aortic prosthetic replacements, and 2 (7.7%) double valve replacements were achieved. Fourteen patients (53.8%) were operated for prosthetic valve dysfunction. Eighteen patients (69.2%) were in NYHA class III or IV preoperatively. Mean bypass time was 85+/-30 min. Mean duration of ventilation was 13.6+/-6 h, mean intensive unit stay was 2.8+/-6.4 days, and mean hospital stay was 8.3+/-7.2 days. Two (7.7%) patients required high dose inotropic support and in one patient (3.8%) intra-aortic balloon support was required. Pulmonary complication occurred in 1 patient (3.8%), low cardiac output in 1 patient (3.8%), and re-exploration for bleeding in 2 patients (7.7%). Operative mortality was not observed. CONCLUSION: Normothermic on-pump beating heart valve replacement offers a safe alternative to cardioplegic arrest in high-risk group. Complication rates are low and perioperative mortality is lower than with conventional surgery. Beating heart technique has the advantage of maintaining physiologic condition of the heart throughout the procedure.

An alternative application of sodium nitroprusside to overcome perioperative spasm of the internal thoracic artery.

OBJECTIVE: The internal thoracic artery (ITA) is currently the preferred conduit for myocardial revascularization; however, perioperative vasospasm of the internal thoracic artery may cause morbidity. Pedicle preparation and pharmacological vasodilatory treatment vary greatly. This clinical study was performed in order to define the effectiveness of two different applications of sodium nitroprusside as vasodilating agent. METHODS: Eighty-six (86) consecutive patients whose left internal thoracic artery was mobilized only by one surgeon for elective coronary artery bypass graft operations were randomly divided into two groups. The internal thoracic artery was allowed to bleed freely, and the flow was determined (flow 1). In group I (n=42) 3mg sodium nitroprusside in 10ml of 5% dextrose solution was sprayed with pressure on the pedicle with a thin 25 gauge needle. In group II (n=44) half of the solution was sprayed in the same manner, and the other half of the solution was injected into the pedicle in the periarterial tissue along the length of the pedicle. Free flows of the internal thoracic artery were registered before cardiopulmonary bypass (flow 2) and also just prior to performing internal thoracic artery anastomosis to the left anterior descending artery (flow 3). With each measurement hemodynamic parameters and the time between measurements were recorded. RESULTS: No statistically significant differences were found between the groups in respect to sex ratio, age, body surface area, heart rate 1 and 2, mean arterial pressure 1 and 3. There was no significant difference in the initial flow among groups. Significant differences were noted in the second flow measurement (P<0.05) and in the third flow measurement (P<0.01) between two groups. For each group there was a significant increase in flow from flow 1 to flow 2 and from flow 2 to flow 3 (P<0.02). CONCLUSION: Sodium nitroprusside injection to the pedicle provides a better flow than simple spraying of the same agent.

Potential risks in coronary artery bypass grafting via mini-thoracotomy: a case report.

This paper describes a patient with an occluded left internal thoracic artery, possibly as a result of the proximal 'steal phenomena', following coronary artery bypass grafting via mini-thoracotomy without cardiopulmonary bypass.

Coronary artery bypass surgery without cardiopulmonary bypass.

In the years 1994 and 1995, 1087 patients underwent coronary artery bypass grafting at our institution. Of these, 297 were operated on without cardiopulmonary bypass. 239 were male, and 58 were female. Their ages ranged from 28 to 81 years (54.43 +/- 9.63). Of the total, 294 were operated on electively, two as a coronary reoperations, and one as an emergency after a failed percutaneous transluminal coronary angioplasty procedure. In all patients complete revascularization was the aim, and a cardiopulmonary bypass team was kept on standby. Median sternotomy was performed as the exposure in all patients, except a patient who underwent a coronary reoperation through a left thoracotomy incision. The average of the distal anastomoses was 1.51 +/- 0.6, ranging from 1 to 3. The left internal thoracic artery was used in 292 operations, which was an individual graft in 284, a sequential graft in five, and a free graft in four. Major complications in the early postoperative period were noted in three patients as reoperation for excessive bleeding. One patient had reoperation for left internal thoracic artery spasm, and one patient had lower extremity ischemia caused by intraoartic balloon counterpulsation. Hospital mortality was 0.3% with one patient. It is our belief that in selected cases coronary artery bypass grafting without cardiopulmonary bypass is a safe procedure with the advantage of improvement in recovery during the postoperative period.

Coronary bypass surgery in a renal transplant patient.

Coronary bypass surgery in a patient with functioning renal graft is reported. Surgery was carried out using standard operative techniques providing some precautions for renal graft protection: i.e. adequate mean perfusion pressure, volume replacement, and renal outflow during cardiopulmonary bypass, and appropriate prophylactic antibiotic and immunosuppressive therapy. Postoperative course was uneventful and blood urea nitrogen and serum creatinine levels were comparable to the preoperative levels. Three months after operation the patient was found to be asymptomatic.

Clinical results of mitral valve replacement with and without preservation of the posterior mitral valve leaflet and subvalvular apparatus.

In this study we attempted to investigate the importance of posterior leaflet preservation during mitral valve replacement (MVR). One hundred and forty randomly selected patients with isolated mitral insufficiency were studied, half of whom had MVR with preservation of the posterior leaflet (Group I), whereas in the other half conventional MVR was performed, without preservation of the posterior leaflet (Group II). Within these two groups there were no in hospital deaths, but 5 patients in Group II were admitted to the hospital with congestive heart failure and 3 of them died after approximately 6 months. Long term mortality rate was 4.2% in Group II. Ejection fraction (EF) decreased postoperatively from 56% to 50% in Group I (p less than 0.05), and from 59% to 49% in Group II (p less than 0.05). Fifteen patients in each group and aged below 30 with sinus rhythm and in the first functional capacity according to the New York Heart Association classification (NYHA) were subjected to exercise study, 18 months after the operation. After exercise EF increased from 47% to 64% in Group I and decreased from 51% to 47% in Group II. These findings suggested that MVR with the preservation of the chordae tendineae can be done with a low morbidity and mortality rate in the early and late postoperative period.

Mediastinitis after open heart surgery. Analysis of risk factors and management.

Mediastinitis developed following 58 of 8803 operative procedures involving median sternotomy at Türkiye Yüksek Ihtisas Hospital. There were 40 men and 18 women. Mediastinitis occurred within, on average, 10 days after the operation. No positive cultures were obtained in 37 patients; Staphylococcus aureus was the responsible pathogen in 18, Escherichia coli in 2, and Enterococcus in 1 patients. Thirty patients had a valve procedure, 24 aortocoronary bypass grafting, 1 a total correction for tetralogy of Fallot, 1 a primary closure of an atrial septal defect, and 2 had Bentall's procedure for an ascending aortic aneurysm. Fifty patients were treated by radical debridement and closed irrigation of the mediastinum with antibiotic solutions and 8 patients were treated with sternal debridement and transposition of the omentum. The mortality rate was 36% for the former, and 12.5% for the latter technique. Omentum transposition promoted rapid healing with a low mortality rate.